doctor said not ethical...blue cross says it's ok

[wickedwanderer]

i've been going to a doctor who gives me bills at each session (therapy) and told me to submit them w/ a reimbursement form to blue cross and that i would get reimbursed for a large portion of the bill.  

blue cross has been denying the claims because she is billing me from a different address than is listed for her practice.  i see her in one office, but her "main office" is the one that blue cross recognizes b/c of the address.  

i talked to blue cross, and the rep told me that if i can have the dr bill me from the main office address, they can reimburse me.  the therapist said that's insurance fraud and not ethical.  i guess my problem is blue cross is telling me it's ok.

any opinions on this?

[InsureBob]

Blue Cross is telling the truth.  Your therapist is not.  When a professional establishes a "practice" address, it has to be a true business address, not just someone working out of their kitchen.  

Why is the therapist not wanting to use the other (legally valid?) address?

The billing address is the main office address, and it SHOULD be listed on her letterhead, forms, etc. It sounds a bit "shady" that she is not using, or allowing you to use, her "main" legal entity address.  Something smells.

Or, have the therapist contact Blue Cross and establish the second address as a legal address for billing.  That would solve your problem also.  There is fraud going on, but not from Big Blue's end.

[Jordy]

I agree with you.  I have to wonder...does it sound like maybe the therapist is pocketing payments and not accounting for them in her practice?  Definitely something fishy like that.

wickedwanderer:  Your doctor's claim of insurance fraud makes NO sense.  Never, ever have I heard that where you are PHYSICALLY speaking to her is where the bill has to come from.  InsureBob is right; the LEGAL BUSINESS ADDRESS must be used; she must have that address listed legally, with her accountants, etc.  It is the only place billing should be happening to AND from.  Accountants, for example, work all over at different businesses all the time doing audits and such, yet their bills show only their LEGAL WORKING ADDRESS.  I agree with InsureBob that there's something questionable going on with your therapist, OR she is completely clueless about how insurance claims are processed.

[wickedwanderer]

thanks for the responses!  i talked to the therapist again and said her boss at the "legal address" says if she bills me from there, he would be liable if something happened to me at the "other address."  the therapist also said the place i see her at is considered a sole proprietorship, while the "legal address" is a regular practice.  i'm confused about this (still).  anyway, since she can't bill me the was BCBS said, she took her price down by $25, which really isn't that much.  i really like her and feel totally comfortable talking to her, which is why i'm really not wanting to find someone else.

aaah!

[InsureBob]

That's fine.  Just don't expect BCBS to pay for the visits.