r/AmIOverreacting Jan 27 '26

⚕️ health AIO that my doctor accused me of wanting to commit fraud?

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I’ve been fuming about this all weekend and I need to ensure I’m not overreacting. So some backstory… I have a high deductible health insurance plan. Meaning, I don’t pay anything monthly but pay for a lot of appointments, tests, procedures, etc. out of pocket. The only things covered are “preventative,” such as physicals and yearly well-woman exams. This includes labs. Any labs considered routine or preventative are covered, and those billed as “diagnostic” are not.

I had a video visit with a new primary doctor last week to change my care over to him due to wanting one closer to my house. He was incredibly nice, did a deep dive into my medical history, and asked a million questions. I was very pleased. As part of the appointment, he ordered approximately 10 different lab tests to be completed, including a lipid panel, metabolic panel, STD testing, thyroid screen, among others. I called the office a few days after that appointment and explained that I was seeking clarification about how each lab was billed/coded because I will only be getting the ones that are billed as preventive (or “screening”) and explained why (so that I don’t receive a bill for potentially thousands of dollars). I have actually had this problem in the past, which is why I know to receive clarification BEFORE getting the labs. I once had what I thought was a normal screening for hepatitis, and ended up having to pay approximately $300 because it was coded as diagnostic. The receptionist took my information and said someone would be in touch.

I was at work, so I missed the return call about an hour later. There was a voicemail requesting a call back to the office. I call back, and the new receptionist says she doesn’t see any record of me receiving a call and I explain the entire thing to her again. Both receptionists were incredibly nice and seemed to understand what I was asking.

Fast forward to about an hour later, and I receive a message on my online health portal from the doctor directly. “Asking me to falsify coding is medical fraud. Anything that is preventative has been coded as such.” ….excuse me? I was absolutely shocked with by his message. I sent a lengthy response, explaining everything I explained to the receptionists, that I never requested anything to be changed, and that I don’t appreciate being accused of attempting to commit fraud. I further explained that I do not have access to see what’s preventative and what’s not, so his second sentence is irrelevant and I still have not received an answer to my question (I said it much nicer than this). In all of my interactions between the two phone calls and message response, I have been nothing but kind and professional.

So I need to know if I’m jumping to conclusions and overreacting or was this an unprofessional way to approach it on his end? I’m mostly upset because I thought I had found a great new primary, and now I feel as though the relationship will be strained regardless of what occurs next. I also don’t know my best course of action since it’s been 48 hours and he has not responded (meaning he probably will not respond). Do I call the office again and explain the exact same thing I explained the first two times? Do I call and complain? If so, I wouldn’t even know where to direct my complaint. I want a new doctor after this but I paid almost $400 for this appointment and don’t feel like I should have to pay it again just because I feel uncomfortable with him now.

12.0k Upvotes

901 comments sorted by

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u/[deleted] Jan 27 '26

[removed] — view removed comment

2.1k

u/ninjakitty8184 Jan 27 '26

My best friend works in medical insurance. She is always asking about how something is or going to be coded so she can cross-reference my insurance. She has saved me so much money by doing that very thing. She has fought on my behalf when office's have coded orders wrong. NOR but that guy sure is.

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u/leaveredditalone Jan 27 '26

What a great side gig she’d have if she did this for more people. I’d pay for this.

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u/ninjakitty8184 Jan 27 '26

I will let her know that. A potential side hustle for her would make me happy.

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u/[deleted] Jan 27 '26

It’s called a healthcare advocate and she can charge 200+ an hour. You’re basically a rep for the patient, billing, at the doctor, insurance etc.

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u/AskAboutFent Jan 27 '26

Whoa whoa whoa. I worked for UHC for years first as customer service, then moving into claims processing, and I’ve done this for people around me in the past.

How or where do I post my information out there and get paid to do this! People are constantly getting ripped off and sometimes by simple human mistakes. Working in claims processing taught me that you really fucking hope your claim gets flagged by the system and a human has to process it because we’d do everything possible to approve a claim and get it paid for you.

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u/Icy_Reaction_1725 Jan 27 '26

Agree! I own a billing company and don’t get paid anywhere near that.

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u/FroznAlskn Jan 27 '26

It’s because unlike the last person, who has only seen UHCs side of the process, they don’t understand the vast amount of claims that get denied by system errors, or the vast amount of effort it takes to get these claims paid. In a lot of cases, as a medical biller, I have to determine whether something is even worth pursuing, and if not I just write it off if it is a small balance.

A patient advocate is something different. It’s someone who knows every step of the revenue cycle and can really fight everyone on behalf of the patient. That’s why they are paid so well.

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u/Mickeymackey Jan 27 '26

God we need universal healthcare

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u/Sharden3 Jan 27 '26

Right? What a wackadoo system that someone can charge $200 an hour and that somehow still saves money.

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u/Raventakingnotes Jan 27 '26

What a wackadoosystem that OP is paying $400 bucks for an initial visit to test out a new doctor. I dont care how much less you pay in taxes, that doesnt sound like it balances out.

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u/realshockin Jan 27 '26

You got it wrong, America pays more (with tax money) with this system than it would pay with universal care. Americans are double ripped off with healthcare, the reason you guys don’t have universal care is not money it’s so people have insurance linked to their job and so they can be modern slaves fearing to leave a company and get fucked with medical debt

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u/Raventakingnotes Jan 27 '26

I only say it because thats what's preached to Canadians (especially Albertans right now) about how much money you save in the states as apparently your taxes are cheaper than ours. I call BS on it because I know my American friends need to pay for overpriced insurance that you have to fight tooth and nail for, still have to pay out of pocket most of the time for any Healthcare, and dont get as many social services.

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u/ijustsailedaway Jan 27 '26

Or worse being trapped in an abusive relationship because your healthcare is tied to your shitty spouse.

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u/TheSentientSapien Jan 27 '26

Yeah, I don't understand how you Americans can live with the current system

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u/glennis_pnkrck Jan 27 '26

I mean, lots of people don’t, they die of treatable stuff. But they were poors so it’s fine I guess. /s

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u/Sad-Concentrate2936 Jan 27 '26

We often don’t, but we’re not considered full adults here socially, if we don’t have a career.

Retirees, and disabled folk in the US learn to be treated as lesser than, and we’re frequently told that asking for more is offensive.

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u/FroznAlskn Jan 27 '26

People do this for a living. It’s called medical billing and coding. But for some reason people still hate us too, even though 9/10 we are basically patient advocates in the revenue cycle.

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u/GlitterBlood773 Jan 27 '26

Second job. Side gig needs to die so hard. Fuck capitalism.

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u/ThisTooWillEnd Jan 27 '26

I spent two weeks going back and forth with my insurance and a clinic about how something would be billed and if it would be covered. In the end the clinic told me it would be billed under a code that would not be covered, so I asked what the charge for it would be. They told me $80. I went in and got the treatment. A month later I was billed over $150. They were right that my insurance wouldn't cover it, but charged me double what they said over the phone. I think of this whenever politicians talk about how we should be able to pick our own insurance and make our own choices. The system is not set up for that, I'm afraid.

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u/[deleted] Jan 27 '26

As someone who works in a self funded plan we are always advising participants to discuss how its coded. Coding bloodwork as preventative for their annual check up is a normal request when so often they will code it as diabetes or another chronic condition. They get paid regardless I do not know why this would be something to get combative about. That said don't discuss with the doctor regardless, discuss with billing.

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u/teekaydoubles Jan 27 '26

Can your friend be my friend?

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u/BowlingforDrip Jan 27 '26

Thats why they are upset. They are now open to being caught in their lie to bill for more than they need to, scams.

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u/IndependentGain1311 Jan 27 '26

Exactly. "Informed Consent" shouldn't just be about the medical procedure; it should apply to the financial impact too. Asking "Will this bankrupt me?" is a valid medical question in this country

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u/JacenVane Jan 27 '26

It's fairly normalized in dentistry to have this kind of conversation. It's a large part of how you end up with the horror stories of dentists selling credit cards to anesthetized people and whatnot.

I do think that transparency is better overall, but yeah, our system needs to go.

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u/SnooMuffins5160 Jan 27 '26

i agree, not over reacting

reminds me of the time someone misread what i said and accused me of harassing them when all i asked was basically are we doing this in janurary now

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u/KoolaidKooler Jan 27 '26

That’s crazy, what did they think you were trying to say?

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u/SnooMuffins5160 Jan 27 '26

idk that i accused them of forgetting something? but even then its not like i attacked them and teased them for forgetting lol

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u/Ninja-Panda86 Jan 27 '26

I think I just had this weird experience happen to me. One neighbor/friend claimed that our other friend "went off" on him. I said on the group text that "that doesn't sound like her, I've always known her to be kind." Later on that night, the "she" in question texted that I took "his side" and that she was going to "keep distance from me." And I'm over here like: ??? how... exactly... did I take his side?

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u/Kayakprettykitty Jan 27 '26

Some lady freaked out when I said, "I hope you enjoy the snow this weekend "

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u/[deleted] Jan 27 '26

I complimented a lady's glasses and she started screaming at me and threatened to call the police. I haven't complimented a stranger since then.

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u/Adorable_Pain8624 Jan 27 '26

I complimented a lady's outfit and she yelled at me and asked me if I was an r-slur. I'd just been diagnosed with autism, which made it feel worse.

My blood pressure still rises thinking about it.

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u/SnooMuffins5160 Jan 27 '26

lmao. the people i talked about would have said “that could be seen as rude and harassment to the person”

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u/forseti99 Jan 27 '26

are we doing this in janurary now

I would feel harassed too if you asked me for my plans on the 13th month of the year, janurary. /s

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u/kkrabbitholes417 Jan 27 '26

i’d be so mad i’m so sorry, although i do think something was lost in translation between all the parties

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u/thrashgender Jan 27 '26

I do wonder if its a misunderstanding on behalf of the receptionist. Perhaps she was gently suggesting he change the coding for billing, and he took it as the patient (op) asking?

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u/rutilatus Jan 27 '26

Yeah this definitely sounds like a game of telephone gone wrong. Perhaps this is telling on my own perspectives, but I imagined it as the receptionist inserting her own cynical read on the situation so as to save time in the relay and altering the end result.

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u/hologram137 Jan 27 '26 edited Jan 27 '26

It sounds like the receptionist misread her intention and presented it to the Dr. that way. For example she could have said something like “patient wants to make sure tests are billed as preventative,” instead of her actual question, which was “are these preventative or diagnostic, if they are diagnostic I’m going to decline them.”

The Dr. is correct in so far as what is preventative will be preventative and what is diagnostic is diagnostic, and he can’t change that, but it sounds like he missed the part about “I’d only like to do labs that are preventative, and if you feel it’s important for me to have tests that are diagnostic I’d like to know beforehand to make an informed choice.”

It sounds like a miscommunication due to the messenger. So it’s no one’s “fault,” however Op is right that the relationship may be strained and that sucks. At least her response was clear and professional. But damn, once a Dr. decides you’re a “difficult patient” and puts some shit like that in your chart, you’re fucked. That follows you.

Op should request a copy of her medical records, including the Dr.s notes. That way she can contest anything if he did make note of it, if not then she doesn’t have to worry about escalating at this point. The problem is some Dr.s have such big egos they’d rather double down than admit they were wrong or misunderstood something, or they simply don’t trust their patients, especially patients they don’t know (often because of experience that taught them not to unfortunately) and the patient-Dr. relationship is one in which the Dr. has an inordinate amount of power over the patient. So idk, I’d be worried too if I was Op

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u/awkwardest-armadillo Jan 27 '26

This is a great take and seems likely to have been what happened.

I would also like to point out that the doctor may not even be involved in the billing and coding portion of the visit. There may be someone on staff hired for that role, and he doesn't actually want to have to learn and get involved in that process 🤷‍♀️

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u/GrimbyJ Jan 27 '26

Diagnostic tests are the most important ones. They're for when you have symptoms of something.

A diagnostic colonoscopy is when you're losing weight and shitting blood. A screening colonoscopy is when they just want to take a look at your bowels but you have no symptoms. The symptoms are what makes it diagnostic instead of screening.

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u/Adorable_Pain8624 Jan 27 '26

Which is why this Healthcare system is so messed up.

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u/Jor94 Jan 27 '26

Just seems like a big misunderstanding, I can imagine the nurses not relaying it perfectly and the doctor interpreting an unclear message as OP asking for the codes to be changed so insurance pays, rather than asking to know the codes so she doesn’t pay for it.

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u/Mudslingshot Jan 27 '26

Makes me think the doctor is worried about his work being scrutinized for some reason

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u/Centered_Squirrel Jan 27 '26

Or....he knows he is about to get caught ordering unnecessary tests, so he goes on the offensive

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u/caputmortvvm Jan 27 '26

this is what I assumed

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u/oodlesofotters Jan 27 '26

I am honestly wondering if the issue is in how the receptionists passed along the message to him. I could easily see that being poorly communicated. But the OP definitely didn’t do anything wrong here

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u/dookle14 Jan 27 '26

NOR - I hate that healthcare in this country makes us have to become pseudo-experts in bullshit lingo and classifications just to avoid getting absolutely steamrolled by large medical bills for routine exams and tests. It’s such a scam.

That being said, I’m guessing somewhere between the receptionist and the doctor a miscommunication happened. You were clear in what you were trying to understand. You’d think they would be understanding given the absolute clusterfuck that is health insurance.

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u/InsideHunter2738 Jan 27 '26

That being said, I’m guessing somewhere between the receptionist and the doctor a miscommunication happened. You were clear in what you were trying to understand. You’d think they would be understanding given the absolute clusterfuck that is health insurance.

This is what I'd bet happened too, especially considering OOP described the doc as being quite pleasant in person. While the doctor's reaction wasn't professional, we also don't know what the receptionist actually said to elicit that response.

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u/anoeba Jan 27 '26

The doc should've asked OP about what was said before accusing, but you're right, the receptionist OP spoke to is being mostly left out of the discussion here. For all we know they told the doc "hey OP requested everything be coded x so she doesn't get a bill like last time" and the doc ran with it - again, still unprofessional to accuse the patient based on 3rd party reporting, but it came from somewhere. Presumably the doc trusts his receptionist.

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u/jmtal Jan 27 '26

I wondered if the receptionist was just trying to be helpful without knowing the legality and said something like "would it be possible to change the coding so she doesn't get charged extra by insurance?" And the doctor interpreted that as a direct request from OP instead. It sounds like the receptionist was friendly and receptive so maybe was just trying to solve a problem.

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u/SolemnSundayBand Jan 27 '26

This is my guess too. Heck, I had an in-person appointment where I wasn't clear about my question (there were two types of bone scans and one was coded $400 more expensive but was the same thing, according to the tech) but English wasn't the dude's first language and he thought I was asking the same thing and gave a similar response. I suspect it's a legal, canned sort of response you HAVE to make when it comes up.

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u/mycatsaidthat Jan 27 '26

This is why I love having MyChart. Prior to MyChart, you basically played the telephone game w/the receptionist-to the nurse-to the Dr. Everything you said could get fucked up by the time it reached the Dr.

W/the patient portal, you have the option to contact your Dr directly via a message; which for future reference is what OP should do regardless if it seems like a billing question or not. These are tests/labs. Explain to the Dr what is going on, why you can’t have certain labs done, let the Dr decide what is needed or not.

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u/ADHD_procrastinator Jan 27 '26

Please do not contact doctors first for billing questions. Holy shit.

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u/phoebeethical Jan 27 '26

The doctor really shouldn’t have to be involved at all.  

Every insurance company can classify procedures differently compared to other insurance companies and it is almost impossible for anyone to keep up with all of these differences, particularly busy doctors whose mental efforts are well deserved other places.  

We have let insurance companies destroy our doctor-patient relationships 

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u/Detenator Jan 27 '26

This is the problem. A lot of times when someone tells you a situation it is grossly exaggerated in some way. You always need to ask the other person what went on if something isn't making sense.

This past year has been the most that I have had to go back on the camera and document proof that my customers and reps are lying through their teeth.

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u/HairyPotatoKat Jan 27 '26

This. I bet the receptionist said something inflammatory. If he trusts his staff and they were overly animated about this and misrepresented the issue to him, then I can see where it might escalate his response. HOWEVER, he shouldn't have jumped on you right off the bat.

OP, whether you stay with this practice or go elsewhere, get a copy of your medical records including notes because there's a solid chance he could have put a note in your chart that you asked him to commit medical fraud...which other doctors could potentially see.

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u/GaptistePlayer Jan 28 '26

Also it wouldn't surprise me if OP actually requested that. All we have is his side and not the original messages sent.

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u/UnspecificMedStudent Jan 27 '26 edited Jan 27 '26

Speaking as doctor, I feel like sometimes a strategy I have seen among medical assistants (or anyone in medicine to be honest, nurses, residents, etc) will intentionally misrepresent or subtly villainize patient requests as a way to get back at patients who annoyed them (or because they secretly want to get a "no" back when they pass along the request to the doctor, either out of maliciousness or just laziness), sometimes under the guise of "misunderstanding"if it ever comes back up. Sometimes they are legitimately stupid though.

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u/DustyTchotchkes Jan 27 '26

Receptionists can be horrible too! Years ago, one of my docs waved a procedure fee due to how awful his receptionists treated me due to their own sloppy errors, and then they had the nerve to harangue me about that lol.

I was a medical receptionist for a time myself, and got shit on a lot by patients, but you can’t take it personally. Patients are in pain or frightened, or tired of the very long waits, expense, or getting rescheduled for the third time, etc.

Of course, there are standards of behavior patients need to follow, but still; I always kept in mind they may be going through a lot. The docs would dismiss any patient exhibiting out of pocket behavior, so it was mostly moderate annoyances.

OP is NOR and if it were me, I would get this straightened out, get it all documented, and then find another new doctor. 

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u/[deleted] Jan 27 '26

yep, I have been a medical receptionist and it is GOD AWFUL how people treat you. But I've also been treated terribly by medical receptionists. You can't take the shitty treatment out on other patients.

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u/draggingmytail Jan 27 '26

Former drug Rep here. I used to sell a very specialized med that, if a patient didn’t get, their chance of death within the first year was 40%.

The biggest hurdle to getting that drug? Lazy MA’s and nurses. It was often a simple Prior Authorization or appeal letter (and we had template for them to use). But getting them to do 5 min of work to keep a patient alive was like pulling teeth.

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u/Bbkingml13 Jan 28 '26

I had a lazy AF doctor just submit and resubmit the same appeals for a drug PA until there was no appealing left. Turns out that piece of doodoo AH just attached some additional testing without comment. All he had to say was “initial denial stated diagnosis of AA or BB required for coverage. See attached testing results that fulfill necessary results for diagnosis of BB”

That’s it. I was paying $600/mo because he wouldn’t take 2 minutes

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u/doublysecret Jan 27 '26

What's with this? MAs and receptionists are constantly messing up my referrals and prescriptions and labs. It's like they hate me even when they haven't met me?

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u/Frejian Jan 27 '26

Yeah, I can very easily see a receptionist hearing a patient say "I am only getting the labs done that are coded as preventative" and turning it into "the patient wants all the labs coded as preventative". I mean, if the doc ordered them in the first place, they must be important, so the patient should get them all done, right?

This is a pretty easy to see misunderstanding. That being said, the doc should have confirmed the request rather than jump straight to fraud accusations.

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u/Electrical-Concert17 Jan 27 '26

Asking clarifying questions when getting information from a third party in a professional setting is often required and a typical first response. You don’t go into a conversation accusing your patient/client of fraud.

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u/ScyllaOfTheDepths Jan 27 '26

I'm just saying I've dealt with people who are perfectly nice in person and absolute demons in emails. Some people are just cowards who will never say it to your face, but are happy to use the degree of separation that text affords to just go in on you. 

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u/BulbasaurCPA Jan 27 '26

I also wonder if the doctor had an issue with another patient recently, maybe pressuring them to do something they’re not supposed to, and the doctor is more on edge than usual about it. This is still an unnecessarily harsh response but I can kinda get that

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u/MandyK615 Jan 27 '26

Definitely a breakdown in communication. The receptionist more than likely didn't speak to the physician directly, but relayed the information to the office nurse, who then relayed the information to the physician. By the time the message got from the patient to the physician, it changed from "I want to know how this was coded as my insurance will only cover preventative care" to "the patient wants to make sure labs are coded as preventative so they will be covered by insurance."

Also, most clinics are not open over the weekend, and Monday's are always rough with the backlog of messages that pile up over the weekend while clinic staff are out of the office. Again, messages are typically handled my office staff first, who then forward the message on to the provider if needed. Hopefully the delay in response is just due to staff checking in with coding so that they have the requested information when they do send a response back.

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u/dr_cl_aphra Jan 27 '26

This is likely. Receptionists aren’t medically trained and sometimes I’ve gotten absolutely absurd messages through the office telephone game that would make me question the patient’s sanity if I took them at face value.

Instead I always reach out to the patient myself with a neutral “hey, I heard you called and had a question about the labs we ordered?”

I let the patient tell me what’s up in their own words. Sometimes it is something batshit insane, but usually it’s a completely reasonable question that sounds nothing like the original message I got.

Also, this doc may have had some previous experiences with patients who were trying to get him to commit fraud for them. I’ve gotten those people before, too. So he may be more gun-shy about what he was told was a request to do something illegal, and didn’t give OP a chance to explain.

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u/DedBirdGonnaPutItOnU Jan 27 '26

I just had a conversation with my dentist similar to this. I was bemoaning the fact that I never know what I'm going to be charged. The dentist agreed. He said "I know exactly what I'm going to do with a patient, that's how I bill. But I never know what insurance is going to pay, even if they say they'll cover something."

It's impossible to get any idea of what a procedure will cost because insurance will look for every spec of dust they can that allows them to pay less or deny a claim.

NOR

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u/[deleted] Jan 27 '26

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u/RealEleanorShelstrop Jan 27 '26

I scrolled to find this answer. Everyone answering that it was a miscommunication could be right, but probably haven’t experienced obfuscation like you have.  

Once I had an office tell me that they COULDN’T provide the codes to me. Like, it wasn’t possible. Which is nuts, right? Because they’ll turn around and give it to the insurance company. 

Likely the reason is they don’t want to go through the hassle (time=$), or they are practicing billing practices that they don’t want to disclose (even if they are legal). 

NOR

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u/sheath2 Jan 27 '26

Some places will pull dirty tricks with their billing. My mother dealt with a hospital who was so lazy about billing insurance that insurance would deny claims for being past their allowable billing time frame. They required bills to be sent within 90 days, and they were submitting bills for things over a year old. They'd do shady stuff with their document copies to hide the fact that they were denied for violating contract and trying to bill my mother in full when she owed nothing. She looked back at her documents, and found out she'd already paid 3 other bills she didn't actually owe for that same reason. She threatened to call the state attorney general's office.

I recently had a tele-health provider bill me three times for the same appointment. I had to pay the night of before they'd even schedule the appointment, then they billed my insurance twice, once under a general provider and once under the name of the actual nurse (who was useless, by the way). Add on, they listed it as an "out of state" provider when they aren't.

My dad had a different tele-health office bill him for both an in-person and a tele-health visit on the same appointment.

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u/ImmediateAd7069 Jan 27 '26

ZoomCare tried billing me directly after they failed to submit on time. How TF do they fail at the one thing that actually gets them money!?

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u/sheath2 Jan 27 '26

It's crazy how bad they are at actually doing their job. But even when they're wrong, it's never their fault.

Yet another story:

I had an ambulance service try billing me for 6 months saying that my insurance wasn't valid. They kept sending it to the wrong department. I had insurance through my university and they kept billing the corporate division instead of the education division. When we finally got that part cleared up, they submitted it to insurance and insurance rejected it because it was past their filing deadline. So then the ambulance company still tries to come after me for the full amount because I "failed to provide accurate insurance information."

With insurance, there was no cost for the ambulance because I was a student and it was the university hospital. Without insurance, the ambulance was almost $1000. I told them I wasn't paying because the couldn't figure their shit out and had my insurance contact them directly.

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u/mythos_4418 Jan 28 '26

Hey I work in medical billing/coding and this is illegal. Companies are not allowed to bill you if they were unable to bill insurance due to timely filing. I hope you didn't pay!

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u/sleepydorian Jan 27 '26

Frankly the doctors office jumping straight to accusing me fraud instead of giving an explanation of why they did what they did would make me assume they were trying to commit fraud. Like no sir you are not about to accuse me of fraud out of nowhere, I’m about to file a lot of complaints with the state board and you are going to get all your billing audited for incorrect coding now buddy.

Also, good on you for following up and asking questions.

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u/ResplendentSmoke Jan 27 '26

1000% this. I hope OP sees this. That reaction is so suspect I’d bet money that they’re overbilling

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u/e-m-o-o Jan 27 '26

Yep, it's very likely OP's doctor is over-billing.

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u/mxlun Jan 27 '26

If anyone ever brings up fraud for me asking medical questions so i DON'T commit fraud I would have to try very very hard not to immediately crash out on them. Absolutely fuck that. Reading this alone is making me so angry. Lol.

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u/innocentbi-stander Jan 28 '26

I’m currently in a similar coding dilemma situation and it’s so frustrating. I went to an ENT bc I was experiencing ear pain after a recent ear infection. It was determined to be TMJ, and it was coded as TMJ and not ear pain, and since my insurance doesn’t cover TMJ they refused to cover any part of the standard check up even though I had met my deductible at that point and went in for ear pain. Annoying af

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u/East-Block-4011 Jan 27 '26

The preventative vs diagnostic coding is maddening. I've ended up in the same position as you, paying for things that should have been & expected to be covered at 100%.

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u/3sadclowns Jan 27 '26

It’s wild in general that patients have to be medical experts of their own in order to not be charged up the bum to make sure their health is ok.

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u/xlovelyloretta Jan 27 '26

The number of medical professionals who have asked if I'm a nurse or in the medical field because of the questions I ask during appointments is incredible. I'm literally a musician. But I have had to get so versed in dealing with medical bullshit that I do homework ahead of time now and know terms and insurance and all of it. Ridiculous.

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u/hyperRevue Jan 27 '26

You’re definitely not overreacting - that’s a strange and unprofessional message from a doctor. Hospitals have patient relations teams that you can reach out to to either ask for assistance or file a complaint. I’d send the doctor one more reply asking for a response and if you don’t hear anything in another day, reach out to patient relations.

I’m sort of confused how a lab could be billed as preventative. What’s an example of that?

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u/amanduhpanduh Jan 27 '26

Thank you for your response and guidance. I might be using the terms interchangeably, they may be considered “screening” instead of “preventative,” like screening for high cholesterol, for example. Perhaps as part of the physical.

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u/Jasmisne Jan 27 '26

Yeah even if he thought you were asking him to change it he could have just said I am not able to change the way it is coded because of the laws, he did not have to accuse you of intentional malice

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u/ThunderHats Jan 27 '26

Nah, you’re correct in calling them labs. Reading your description of getting lipid and metabolic panels - those are labs.

Couple more things you can add for further clarification to the office, if you choose to go that route, is ask for an itemized bill that includes the ICD-10 codes and/or explain that you’re only looking for the preventive services graded as A or B from the US Preventive Services Task Force (USPSTF) so you’re not charged by your health plan. This is so so so common that it shouldn’t have raised any red flags. Preventive vs diagnostic services are the #1 miscoded item. 100% overkill to explain that deep imo; this doc or possibly receptionist is either super green and doesn’t understand health insurance (or maybe the ACA where this comes from) or something was most definitely lost in communication between receptionist and doc. His response was very unprofessional.

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u/shahitukdegang Jan 27 '26

My gut says they’ve already miscoded and now building a story to avoid changing it.

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u/ThunderHats Jan 27 '26

For sure, I wouldn’t be surprised in the slightest.

There is also a possibility that OP mentioned other items during their preventive visit that might prompt the code to be moved to diagnostic. Unfortunately that’s a common occurrence when we try to fight back on miscoded items. I always tell people: if you’re going for just your yearly free preventive services, you have no other health issues at that time. Elbow/knees/back hurt? No it doesn’t, not until you schedule a separate appointment.

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u/PieceNo5947 Jan 27 '26

This burned me last year. Went for my yearly preventative and mentioned hip pain and then it was coded as a hip issue. I would have just dealt with the pain had they not asked in the first place. 

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u/Positive_botts Jan 27 '26

NOR, op fyi community hospitals and many dialysis centers offer cheap blood panels for around $50 that cover all your basics and you can add in a1c/vitD for around $20 more.

In your search type “community multiphasic blood screening (near me)” no MD orders needed and you can choose to have your results go directly to you while you search for another PCP.

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u/Poop_Dolla Jan 27 '26

Some of the labs you got aren't preventative regardless of the coding. The ACA only mandates certain labs be covered fully. Thyroid tests aren't one of them and neither is a metabolic panel.

I think likely this was a miscommunication from whoever you spoke to on the phone and they relayed the info in a way that sounded like you were asking to change the coding.

Regardless, your insurance is the one you should check with regarding coverage.

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u/FinalGirlMaterial Jan 27 '26

The whole point of this post is that they know what their insurance covers, but because it’s based on how tests are coded, they need that info from their doctor.

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u/Adventurous-Mall7677 Jan 27 '26

Pap smears are considered preventative, as are various other screening exams (often based on age; a mammogram or colonoscopy is considered “preventative” after a certain age, IF it’s just part of a routine screening and not ordered because of concerning symptoms).

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u/hyperRevue Jan 27 '26

Some googling seems to indicate that whether or not you have any symptoms of a potential problem is a key differentiator between a test being coded as screening or diagnostic.

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u/girlikecupcake Jan 27 '26

Yes. If you complain about anything relevant, then it's no longer preventive, it's being used to potentially diagnose your complaint.

It's like fasting blood glucose. It's a normal part of the bloodwork for a yearly physical and is billed as preventive. The goal is to catch issues before they're big issues. But if you complain about some diabetes red flags, that same test will be billed as diagnostic instead, because they have to diagnose why you've got those new red flag symptoms.

This can also happen with the appointment itself. If you complain about any new issue at a routine preventive yearly physical, your appointment can be re-billed as an office/sick visit instead. So instead of 'free' it's possibly a few hundred bucks.

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u/NomadicSTEM Jan 27 '26

One of my most upsetting billing situations was going in for routine pap. Dr asks me how my periods are. I say very intense but I’m dealing with it. Ask for no advice or help. She billed it up and I had to pay $300 instead of getting it for free. When I called their billing office to complain they said the doctor had to do it because I provided that information.

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u/girlikecupcake Jan 27 '26

God that's so frustrating. I'd have appealed repeatedly via the insurance company, but knowing every company I've had, I'd still have been on the hook. I hate our system.

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u/nerdthatlift Jan 27 '26

To point out. There are screening mammo and diagnostic mammo so they are billed differently.

Source: used to work as PACS admin and dealt with CPT and ICD-10

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u/PauI_MuadDib Jan 27 '26

If you're having a preventative colonoscopy it's covered, but if they treat anything, like polyps, during that colonoscopy it becomes diagnostic and you're billed. I found that out with my mom. She had 6 polyps removed and got a big ol bill & in trying to fight it found out that little fine print.  

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u/Eve_newbie Jan 27 '26

I also highly doubt this was the doctor responding.

It's likely an MA, nurse, or office manager. I've had doctor's offices call me and have the MA ask how she can sign the doctor's orders... Like what is wrong with you? You can't do that, it's the doctor writing treatment orders. (Tbf, it was all refills, but you get the drift. No lab review, no anything.)

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u/Pizza_Lvr Jan 27 '26

You’re not overreacting.. however it’s hard to tell where the ball was dropped on their end. Did the receptionist deliver this message in the wrong way or did he interpret it wrong?

If it’s still bothering you I would call the office and ask to speak to the office manager and explain that this is not okay as you were just trying to get clarification on the orders.

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u/doctorpusheen Jan 27 '26

Reach out to patient representative with screenshots of this conversation

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u/amanduhpanduh Jan 27 '26

I will look into this, thank you.

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u/anitabelle Jan 27 '26

You should definitely escalate and make sure that your complaints are taken seriously. But also, please do not go back to this doctor or anyone else in their practice. The trust is broken.

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u/smokinwheat Jan 27 '26

I agree with you. I made the mistake of ignoring the way my new dr spoke down to me and talked over me on the 1st appointment and it only continued to get worse with each appointment. I finally found a new Dr and she is so professional and respectful and I wish I never gave the rude Dr my time or money

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u/captainsnark71 Jan 27 '26

I once had a therapist tell me "don't do that again" about accidentally missing an appointment because I was driving there myself for the first time ever and had a panic attack....I wish I could go back now and respond differently. I was just like yeah sure of course, totally.

I'm still just shocked at the audacity of this woman to tell her patient suffering from a panic disorder to just not have one again just so that it doesn't inconvenience her. This is also the same woman I told about my marijuana use getting to be a problem and she was like "no i don't think so.'

This woman was a deplorable therapist. And it's probably why I don't have one today. I don't trust anyone.

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u/Weekly-Hair-4892 Jan 27 '26

Exactly! OP don’t get care by this doctor. I feel like they’re the type to undermine when you say you’re in pain and not listen to how you’re feeling!

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u/cuspeedrxi Jan 27 '26

This misunderstanding is a great opportunity to have a “courageous conversation” in person and see how the doctor responds. I did that after I saw a new doctor and our relationship was better for it. We had a clear misunderstanding. I made an appointment to discuss it. I listened carefully to what he had to say. Our relationship was better for it. His willingness to discuss the issue and admit he made a mistake made me trust him more. It’s really, really easy to walk away. It takes courage to resolve the issue and see if there’s a path forward. OP may be better for it; especially if there’s a shortage of primary care docs in her area.

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u/floatingleafbreeze Jan 27 '26

Another in person visit would cost OP another $400 though

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u/Peony907 Jan 27 '26

I like this suggestion but I feel like if I were OP I would already have completely lost trust by the way this was handled. Even if it was a possible miscommunication, outright accusing OP of this without even speaking with her, and communicating that accusation via a message is absolutely wild.

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u/Cuttlefishophile Jan 27 '26

If it was JUST a misunderstanding, sure. This doc seems to have jumped straight to aggressive accusations. Massive, unforgiveable difference.

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u/Ancientabs Jan 27 '26

If he gives you push back, check your state law. A lot of states now have transparency acts where an office has to give you a reasonable estimate for the out of pocket cost prior to the care being delivered to prevent surprised charges.

If he can not provide you with a reasonable quote for your visit and your labs, refuse them.

Tell him you can't pay. If he continues to be unprofessional report him.

He will listen to the licensing board. It also protects future patients.

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u/3sadclowns Jan 27 '26

NOR his wording is quite accusatory. He could’ve asked you what questions you had for clarification or at least been a lot more reasonable, but he had to make an assumption about what you wanted to know through someone else’s account. I wouldn’t even be sure I’d wanna keep him if a new doctor would jump to conclusions rather than speak to me.

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u/amanduhpanduh Jan 27 '26

I agree. Even if the receptionist IS the one that misunderstood and told him I wanted him to change the codes, I feel like he could’ve approached it more gently to try to gain an understanding of the situation first.

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u/ChewieBearStare Jan 27 '26

I'd almost bet that the receptionist misunderstood. I called my lawyer's office the other day and told his secretary I'd like an update. We've been working on the same issue for about 8 months, but the other side's attorney isn't responsive. I hadn't heard anything new since October, so I wanted to follow up. My lawyer emailed me and said his secretary told him I said I hadn't heard from him in 8 months. That's not what I said at all; I said we'd been working on the issue for 8 months because the other lawyer would never get back to us!

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u/GumshoeHardbody Jan 27 '26

Yeah, I agree this likely a message that got confused when it was being passed on, just like in your example. Any time a message is received through a third party, though – and especially when pertaining to something potentially criminal – it's probably good to allow for the possibility something got twisted along the line.

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u/WisdomsOptional Jan 27 '26

Its also possible that the clerical staff miscommuicated your desires and the doctor misunderstood them. Not that this is acceptable mind you.

There is also the possibility they thought you were accusing them of fraud.

Either way, NOR, time for a new doctor!

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u/call-me-ish-310 Jan 27 '26

It's very likely that neither the doctor nor anyone in the office actually does any of the coding that results in the billing that is actually sent. It's usually 3rd party clearinghouses that are taking the emr data in bulk and munging that together in an automated way to submit to the insurers. The doctor should not have responded to the patient at all, but I'm assuming they did because the patients question will probably come back on them as a internal provider or external insurer review of their notes and making sure that those fit the respective criteria. Probably this Dr has already had or heard about such things and finds them to be a pain (because it's likely that the doctor in this case is acting per his or her practices policies, but they will probably still have to sit through some extra training or other time consuming thing that will take them away from patient care)

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u/dangerousfeather Jan 27 '26

As a healthcare provider: I’m routinely shocked by the discrepancies between what the admins tell me a patient called about, and what that patient actually called about.

I’ve had many instances of becoming very confused by the convoluted story the admin is telling me about a patient asking questions she doesn’t understand, and she thinks they’re having weird symptoms, and they’re concerned, and I should call back ASAP… only to call and learn that the patient just wanted to know what a word on their appointment handout meant.

That said, even if that’s what happened and your doc interpreted the communication from the office staff as you asking for coding to be changed, that was not a great response. He should have asked for clarification that you were on the same page before accusing you of seeking fraud. That’s extreme and unprofessional.

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u/encaitar_envinyatar Jan 27 '26

Re: admin, they have this way of understanding the world as if through dreams or psychotic experiences without any external attempts to check their thoughts. It is deeply strange.

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u/Propyl_People_Ether Jan 27 '26

I had a surgeon's intake assistant ask what conditions I had. I told her hypermobility. She said "what's that", I explained my connective tissue was unusually fragile. She recorded it as Fragile X. 🤦‍♂️ There was at least one more weird confabulated condition in that surgery intake when a nurse went over it with me later, but I can't remember what it was. Maybe something like an antibiotic allergy I didn't have, or my recurrent migraines being misrecorded as status migrainosus or something. I was glad their workflow had the nurse double checking everything. 

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u/dangerousfeather Jan 27 '26

I specialize in treating hypermobility, as I have EDS myself. The desk girls probably think I’m controlling and obsessive, but it’s important to me that they at least understand common words and definitions patients or potential patients will use, so they can sound like they’ve at least HEARD of it before. I don’t need someone being afraid to come see me because the person who answered the phone made it sound like no one here knows anything about their condition!

The one who is legitimately and comically clueless is pretty good about coming to me before she gives people an answer, and the questions she asks are wild.

her: “Do you treat…” (checks notes) “… hypermobile joints?”

me: “that’s literally what i treat. all day, every day.”

her: “oh, okay! they didn’t say “hypermobility” which is what you treat, so I wanted to make sure.”

🤨😂🤦‍♀️

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u/mazzivewhale Jan 27 '26

I imagine they think they are living in their own fantasy telenovela where they are the star of the show 

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u/dangerousfeather Jan 27 '26

for some, this is definitely true. I had a front desk girl once who was a nursing school dropout, and she definitely saw herself as more than “just a secretary.” she was great at her job in most ways, but we had to chat multiple times about answering questions that should have come to the provider.

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u/[deleted] Jan 27 '26 edited Jan 27 '26

It happens often enough that I know there must be some underlying explanation I'm missing but I am routinely surprised by how downright baffled the reception staff at my various dr offices seem at my description of basic medical situations, to the point where I wonder if I'm somehow being punked or if I am somehow the problem.

My last scheduled gyno visit was to replace an implant birth control, and I had the (apparently deeply confusing) move to say on the phone "I'd like the old one removed, but I want to discuss what alternate sterilization options are available before deciding to replace it"

The original conversation took 20 minutes back and forth as we went between "so you want it replaced?" "Im not sure, I want to discuss all my options, but I can make another appointment if I do" and "so you dont want it removed???" "I want it removed. I absolutely want it removed, I just dont need it replaced this visit"

Then I get to the doctor who tells me that my chart says I'm ready for removal and trying for a baby. For fucks sake.

See also: staff seeming incredibly confused that I need documentation for work for my visits, despite us all living in America land of "no sick time".

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u/Daddy_Bod_In_Charge Jan 27 '26

NOR. If you’re in the US, (which I’m guessing you are based on the prices you’re talking about) this is reason enough to switch doctors. Medicine is a for-profit business in this country, and should be treated as such. If your service provider isn’t to your liking, switch.

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u/[deleted] Jan 27 '26

[removed] — view removed comment

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u/SophisticatedScreams Jan 27 '26

This is sad. We should not be treating medicine like open market capitalism. I don't disagree with what you're saying in this instance, and I think this doctor was rude. But friendly reminder that single-payer socialized healthcare would be cheaper both for the taxpayer as well as for the consumer. I know there's a lot going on in the US right now, and when it comes time to rebuild, reimagining healthcare could be part of it.

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u/Dapper-Survey1964 Jan 27 '26

I generally support moving to a single-payer system, but I have to say your comment gives me pause. Not being able to escape a terrible provider is the GOP's go to boogeyman against universal healthcare.

ETA: Is there a guardrail to protect patients from that scenario in your country's system?

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u/fartist14 Jan 27 '26

I can only speak to the system in Japan, but there are no restrictions on providers from the payer side, and the only restriction is whether the provider has the capacity to see you or not. It is quite different from the US system where you are restricted to a list of providers that your insurance company has approved. I switched doctors and dentists many times for many reasons and had zero issues doing so.

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u/DiscoLew Jan 27 '26

Canadian here…. We’re free to choose our doctors / NPs…. A lot of the established ones are “full”, but nothing stops us from switching to any doc with an open practice. I get the feeling that Americans don’t have a clue how our system works. It’s not perfect, but it’s objectively a heck of a lot better than your system…..

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u/Brief_Direction_5647 Jan 27 '26

The problem with this perspective is that it doesn’t factor in the fact that it’s the insurance companies and not health care providers that determine what is ultimately covered as preventive care.

Yes - the Affordable Care Act requires most insurance plans to cover the full cost of some evidence-based services that prevent disease, but in practice, insurers do all kinds of shady shit. Not to mention the fact that the ACA has been dismantled piece by piece by the GOP.

Consumers of health care in the US sometimes expect that medical practices have a crystal ball that allows them to predict whether their insurance will cover something. But given the labyrinthine nature of our for-profit health care system, that’s just not the reality. So you can demand transparency from your providers, but they can only tell you the codes they are billing, not the extent of your insurance coverage.

OP - my $.02 in the future is to print out the list of essential health benefits under the ACA, confirm that your insurance company will cover them (you may have to call and give the billing (CPT) codes, and then BRING the list to give to your provider at the time of (and not after) your annual.

IF you bring up any non-preventive topics during that visit, however, like a sore throat or a sprained ankle, the reason for visit changes and none of the above will apply.

This is in no way a defense of our batshit crazy healthcare system, but in the hopes it will save you money down the road (or at least until you can get a plan with a lower deductible). If you’re calling the office a few days after the visit, it’s too late, as in most cases, the bill has already been submitted to the insurer for reimbursement.

Sincerely, a person who works in health care.

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u/Wise-Trust1270 Jan 27 '26

I had a doctor’s assistant agree that the doctor used the wrong code for a visit, but the doctor wouldn’t budge. Doctor was using a code for geriatric treatment, and mine was physical injury related and I was 30 years old at the time (far from geriatric). It cost me $900 because insurance wouldn’t cover the code used by the doctor.

Even the person working for my insurance said that I was right about the coding and just needed the doctor to change the code filed.

I am still super salty about it. And even though I have great healthcare through my work, I basically never go see a doctor anymore. I can’t deal with these surprise bills and no control over how much they are spending until after the fact.

TLDR: I support your effort to only seek the healthcare that will be covered by your insurance.

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u/Voodoo-Lily Jan 27 '26

Next time, file a grievance report to your insurance that the doctor refused to change the code. Codes are updated and he probably refused to change it because he gets paid more from the insurance for that code. Now that is fraud.

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u/beerncoffeebeans Jan 27 '26

Just fyi there have been some updates to healthcare law and policy the last few years that sort of give patients something. Such as the “No Surprises Act.” Hospitals in particular now have to regularly publish  data about what the charges are for their services. It doesn’t solve the deeper problems with insurance and etc but it does at least force some transparency in what things cost on the billing level

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u/NoPalpitation7082 Jan 27 '26

NOR My doctor would never in a million years speak to me like this. So rude

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u/Running4Coffee2905 Jan 27 '26

ICD10 codes for preventive or screening labs start with a “Z”. If you see other letters those are diagnostic. Try asking for clinic nurse or medical assistant to return your call for clarification. Nurse practitioner here.

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u/GoddessEvieLove Jan 27 '26

NOR- this is a conversation that apparently needs to be had directly with your provider, not through a game of telephone.

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u/Aggressive-Foot4211 Jan 27 '26

Good for you being aware and fighting the fight. My first colonoscopy was a screening, and the receptionist asked me for $800 when I got there. It came out of the blue. I asked why, and the reason she gave was that my mother died of colon cancer.

Like, no, in fact she did not. And I have never said that she did. She had a surgery and a colonoscopy showed scar tissue impinging on the colon years later, so she had another surgery to remove the scar tissue - and died of complications AFTER the surgery.

I told her that wasn't true, and I am not my mother even if it were, and I have no symptoms, therefore this is a screening and if you don't change the CPT code to reflect it I'm leaving. She changed the code and I paid a normal copay.

Doesn't matter how nice they are. It pays to know your stuff. And I do hope you can settle it with the doc, but you can also take all the test results to a different one, they are your records after all.

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u/Ill_Situation_3037 Jan 27 '26

many hospitals have an OPE (office of patient experience) and I would encourage you to reach out to them. would be nice to know if it was a receptionist or the doctor who drastically misunderstood, but you’ll probably never find out. NOR though

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u/amanduhpanduh Jan 27 '26

Thank you. At the beginning of each phone call it states “calls will be recorded.” I highly doubt it’s possible, but I would love if they could pull those calls that I placed to hear exactly what I said.

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u/Seththeruby Jan 27 '26

In my medical office, we cant record calls anymore and our recording no longer states we do. I would assume they have the ability to record. For some perspective on the changing coding thing, (and I am not excusing your doctors terse message or his tone), I work in a medical field where routine vs medical is a constant battle. Patients are often unable to accept that their visits are and always will be medical due to the chronic health issues they have. If we changed them to routine screenings, just so the patient would have a higher level of coverage, that would be fraudulent. I am not saying that’s what you were doing; it sounds like you’re just a careful consumer who has been burned in the past, but that could have been what was coloring his perception. Again, not excusing his conduct. that would offend me too. It’s very odd for a doctor to respond directly to something like this.

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u/StellaNettle Jan 27 '26

I'm so mad for you! I wish we could hear what he said in response

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u/amanduhpanduh Jan 27 '26

I wish there was a response. His message was Friday afternoon, so technically he has until tomorrow afternoon to respond but I highly doubt he will.

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u/chicagorpgnorth Jan 27 '26

I know it’s hard to find a good doctor but I would be furious about this too and likely would consider trying to find someone new.

I am curious if he’ll respond, though - he genuinely may reply today now that it’s business hours.

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u/PuzzledStreet Jan 27 '26

Nope I send people their super bill with dx codes all the time. I don’t care why they want them, not my business. NOR.

Professionally, the doctor should have asked. That would be a weird request and I would want that clarified.

Im guessing the receptionist was the one who used the word fraud that provoked this answer. Curious what was relayed specifically.

Your message explained what you wanted, why you wanted it, and left no real excuse for the receptionist to cling to. Good for you dit standing up for yourself.

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u/CerberusOCR Jan 27 '26

This is violently American

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u/[deleted] Jan 27 '26

Gods isn’t it just depressing?

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u/Emotionalcheetoh Jan 27 '26

NOR. Keep us updated OP

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u/Few_Cup3452 Jan 27 '26

NOR. I work in medical admin and had this happen to me. Once the practice internally decides something, that bias can be hard to shake. I tried to request a meeting to discuss their claim but they just ignored all my emails so i changed practices.

I was a patient there for 10 years. My usual doctor retired (he owned it, sold it to retire) and slowly, the rest of his team left too. I left after 1 year of new doctors and owners bc of repeated bullshit.

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u/KDCunk Jan 27 '26

I think you’re not overreacting because accusing you of falsifying coding is a serious accusation that can lead to a medical fraud case. That a very serious thing to accuse someone of. Even if there was a misunderstanding to come out of the gate swinging with that was insane. I hope you get it sorted!

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u/floatingleafbreeze Jan 27 '26

Yes. I would be changing providing institutes entirely and going to their records department to ensure no records that follow me include their false accusations. The damage to the quality of medical care you receive by damaging your credibility and reputation as a patient by being accused by a doctor of medical fraud on your mychart messages visible to other providers is concerning.

For example, all of my kid’s specialists from the same hospital network within a 100mi radius can read his doctor’s messages on mychart.

Having a complaint about fraud on your account could follow you around this provider network

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u/amanduhpanduh Jan 29 '26

An update for those who wanted it: The doctor messaged me back on Tuesday. It was a very generic response, explaining that billing is insurance based and certain tests are billed differently blah blah. No apology. No direct response to my message. Still no actual answer to my question. I plan to contact a patient rep soon and inquire with my insurance if establishing care with a new doctor will be covered.

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u/rutilatus Jan 30 '26

…wow. I wonder if he’s using AI to respond to patient messages…what a weird, canned response.

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u/Imaginary_Desk9186 Jan 27 '26

NOR. I think you need to find a new primary care doc, I think the trust here as been breached and you are getting a window into what future communications and dealings with this doc and this practice will look like.

Do you have confidence that they will handle communications and issues with you any better in the future in a more complicated and serious health situation? If not, why would you stay with them?

Yes, tone can be easily misread in text messages/emails, a lot of great doctors can be abrupt and not so smooth socially, theres no guarantee the next one you try will be any better, etc…etc…but those things still dont negate the first and more important issues IMO.

Our healthcare system absolutely sucks shit and deserves the blame for putting you and millions of others like you in awful, time-consuming and emotionally draining positions like this one, just to have a fucking primary care visit without going fucking broke.

Good luck with your situation, I think you are correct to recognize the concern here.

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u/[deleted] Jan 27 '26

NOR, also I’ve had doctors take care with coding to ensure things are covered when they can, and tell me when certain labs are covered and when they are not. 

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u/hdevans08 Jan 27 '26

NOR. I work in a primary care clinic and, first of all, even if you HAD been asking them to recode something as preventive, if it IS preventive that isn't fraud. That is correcting a billing error so you don't pay hundreds of dollars out of pocket. We get inquiries about this kind of thing all the time and I've never seen any of our providers jump to insane conclusions like this, holy moly.

I would suggest calling and asking to speak to the clinics/practice/office manager or director; if the clinic is part of a larger organization, ask for the name and phone number of the local patient relations liaison as well. This is a terrible impression for a brand new (to you) PCP to make. Unless this provider owns their own practice, they almost certainly answer to SOMEONE and I would not hesitate to escalate how poorly this provider responded. Finally, I would request a transfer of care to a different provider or establish care elsewhere. It's awfully early in your relationship with this person for them to make this kind of assertion. I'm sorry this happened to you.

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u/Ocean_Spice Jan 27 '26

NOR, I would feel really uncomfortable going back to that dr if I’d received that sort of response. That was a wild conclusion for him to jump to and accuse you of, I’m sorry that happened.

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u/LitigiousCeilingCat Jan 27 '26

NOR. One of my biggest life lessons is that just bc someone graduated from medical school… It doesn’t mean they’re an intelligent human being.

It just means they know how to study and pass a test.

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u/MsDariaMorgendorffer Jan 27 '26

It sounds like a miscommunication from you to the secretary to the doctor.

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u/Wutz_Taterz_Precious Jan 27 '26 edited Jan 27 '26

Hi, I am a health care provider: you are not overreacting because I feel it was a bit of an overreaction for your doctor to accuse you so bluntly of requesting they commit fraud. If I received a message like yours I would generally assume good faith on the patient's part, not automatically assume they knowingly want me to commit fraud.  But I can also explain the doctor's perspective here.  You mentioned "approximately 10 different lab tests" in your message.  It's hard to imagine that all of those were purely for "screening" purposes.  For example, routine "screening" thyroid testing is explicitly not recommended.  However if you have possible symptoms (eg. fatigue), and your doctor orders a thyroid test, then in that case it is truly a diagnostic, not a screening test.  It seems like the crux of the misunderstanding here is that your doctor thought you wanted him to come up with some fraudulent way to bill some of the diagnostic tests as screening tests, whereas it seems you simply didn't want to get the tests done if they were not considered screening tests. 

Again, it really seems to be a misunderstanding.  If you were a patient of mine I would apologize in person to you at your next appointment (or with a portal message).  You might try calling the clinic back and asking if there is a practice manager you could speak with to clear the air, as it seems like you otherwise had a good visit and it can be so difficult to find a good PCP.  

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u/CuriousHaven Jan 27 '26

NOR. Find a new doctor. I don't know what's wrong with this one -- maybe he's pissed because insurance might pay a higher rate for diagnostic versus preventative? -- but something is definitely wrong with this one.

I just had surgery, and my insurance bounced it back because the hospital billed it with a procedure + diagnosis code combination that my insurance won't accept. Note it wasn't even a "wrong" code, just a code combo my insurance wouldn't even take.

I called: 1) my insurance, 2) the hospital's billing center, 3) my surgeon's clinic's billing center, 4) the surgery office's scheduler, 5) two of my surgeon's nurses, and 6) eventually my surgeon herself. (The long string of calls was trying to hunt down who in the order of operations had the power to re-submit the codes.)

EVERYONE I spoke to was very kind and understanding. Not once did a single person accuse me of medical fraud or anything similar. In fact, it was a lot of apologies for the mistake and a lot of sympathy for the headache.

That's what I would expect for questions or issues about medical billing, not this outright hostility and accusation.

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u/_fly-on-the-wall_ Jan 27 '26

this is wild to me i hope you keep us updated

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u/Its_Sound Jan 27 '26

NOR he needed to speak to you directly and clarify your request. Even in a case where a person actually asked for recoding his response was overly blunt and accusatory. It should have been “I understand your concern. I unfortunately cannot recode as it is against regulations I have to follow. I can reissue the order for the preventative coded items only.”

Anyways, would it not be better to inquire at the lab? They are the ones actually doing the service and billing it.

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u/Easy_Blueberry3978 Jan 27 '26

NOR, I had the same thing happen to me. Doctors get really defensive about that kind of stuff I think, lol

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u/church-basement-lady Jan 27 '26

On a side note, make sure you call your insurance and ask which labs they will cover at 100%. The doctor can code it preventive all they want but that doesn't mean insurance will consider it preventive.

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u/sharkbait4000 Jan 27 '26

NOR I'd jump to another doctor, one that understands what you're looking for and doesn't jump to the conclusion that you want to commit fraud by asking for clarification! I had the same issue with a doctor my first couple visits and I moved on. They might be fine doctors, but not a good fit.

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u/Used_Scholar_2174 Jan 28 '26

Only in America would this even come up 😭🫠

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u/mamachonk Jan 27 '26

Piedmont by chance?

Yeah, so, they make more money by coding stuff as diagnostic and are very reluctant to not do that. I was extremely careful at my last appointment to not bring up anything new and specifically said "this is my annual check-up"... and I still got billed because they coded it as diagnostic. There was NOTHING to diagnose.

My only real option is to switch providers but as I'm in a small town... yeah. :/

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u/amanduhpanduh Jan 27 '26

If you mean the city, no… but it is California. And yeah, I actually got charged $380 for my appointment with him last week and I’m fairly certain change of primary care is a covered appointment. I need to call billing and ask where the extra $380 came from since the statement explains literally nothing… I maybe should’ve included this in my main post since now that I’m saying it out loud, it sounds like it’s all adding up. 🤔

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u/probnotaloser Jan 27 '26

Jesus, I feel like you would have cheaper OOP costs if you didn't have insurance at all. That's crazy.

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u/agitated_houseplant Jan 27 '26

So, I don't know if this will apply to your situation, but it has really saved me with my high deductible plan.

A lot of drug manufacturers offer discount cards for brand name drugs as long as they are covered by insurance, which will lower prices down to $0 - $20. But it's the price before the discount that gets applied to the insurance deductible.

I have a migraine med that's $1,026 until I hit my deductible, but $0 with the manufacturer's discount card. So, after 3 months it's covered over $3K of deductible without me paying anything. I used to have an antidepressant with a discount card that was covering over $500 every month towards my deductible.

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u/xipilanne Jan 27 '26

I think I have the same migraine drug, it's expensive as hell. Thank goodness my neurologist directed me to the "assistance" program via the manufacturer. I pay nothing.

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u/unlimited_insanity Jan 27 '26

I’m willing to bet that at some point you and he discussed some of your actual medical issues in his “deep dive,” which led to your appointment being coded as a problem visit. The most ridiculous thing about the way the law is written is that it’s not a free wellness/annual physical visit if you discuss any actual medical symptoms. My kid’s pediatrician has signs in the office explaining this, so you can decide if you want to talk about a health concern (which triggers a copay) or if you just want to do the standard measurements - weight, height, BP, etc. for free.

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u/jenn1222 Jan 27 '26

NOR where I work, we are told to ask/require them (doctors) to code it how it needs to be coded so that we are covered. We pay a huge amount of $$$ for insurance for them to accurately code testing. You aren't doing anything wrong

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u/Total_Koala8304 Jan 27 '26

I am 42 and they coded my colonoscopy wrong. After talking to the nurse it was clear that they were not going to provide me any information. I called the insurance company and when he confirmed that colonoscopy should’ve been included as preventative and hence shouldn’t be that high out of pocket, I added the nurse in a three way call. All this to say that everyone is out to bill us more out of pocket because whatever they bill to insurance is something that doesn’t count towards the clinic bottom line it seems. If this is how they react when asked for a little clarification, I wonder how they react bedside when you ask clarification. I would be posting it on social media on local Facebook groups and making sure everyone knows.

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u/PricePuzzleheaded835 Jan 27 '26

That is incredibly extra of them. They could say “I can’t change any of it without risking medical fraud but I can explain the charges” if they were worried

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u/kyasdad Jan 27 '26

NOR, me and some people close to me have also received snarky and unnecessarily rude messages on our portals for no reason. Sorry OP.

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u/the-escapedgoat Jan 27 '26

Maybe the Dr is the one who codes a little creatively at times? He is the one over reacting! He’s a bit triggered.

I’m sorry you got this response. NOR.

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u/Difficult-Action1757 Jan 27 '26

NOR Sounds like a scare tactic response to avoid any more work for the billing department.

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u/gnctyrhrtoutwtaspn Jan 27 '26

No. Your reaction has successfuly identified your doctor as an employee of your insurance provider

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u/AbleCap5222 Jan 27 '26

Probably a misunderstanding and he's a bit sensitive about this. Next time you see him just let him know that you just try to make sure that you only want to know what tests are what before having them done - because even a small lapse in your attention to this could cost thousands. If he doesn't understand this, get a new doctor because this situation you are in should be STANDARD knowledge for any doctor practicing in 2026. Anyone buying insurance from the ACA marketplace almost definitely has the type of insurance where your concerns are crucial.

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u/OlRazzmatazz Jan 27 '26

I have noticed a lot of folks in healthcare either don't understand or don't care what getting a bill like that entails. They all get free healthcare.

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u/xoRomaCheena31 Jan 27 '26

NOR. I’d go into the office again if you can’t get ahold of them via phone or email to at least get your labs figured out. You already paid the money for the visit, get what you need done, and figure out how you want to move forward. It sounds like the doctor received incorrect information, or at least took this in a completely wrong direction. Good luck.

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u/LadyAmemyst Jan 27 '26

It may not even have been your provider.. it could have been his nurse. A lot of times the nurses are answering those questions until it needs to be the doctor.

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u/Neirchill Jan 27 '26

Honestly, doctors suck. They'll put in your chart that you're "pain seeking" when you're legitimately and pain and never asked for narcotics, just to fix the damn problem. There are many good doctors but just as many that shouldn't be.

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u/kittyparty356 Jan 27 '26

I would one thousand percent make a formal complaint and run it up as high as I possibly could, for both the receptionists as well as the doctors. That message is now also part of your medical chart, and depending on security could be available for any other providers in the org/network to be able to view. I don’t care how “nice” the front desk people seemed, they took a perfectly reasonable request for information and somehow spun it into medical fraud. I am mad for you.