Draft:Boiler-Room Billing

Boiler-Room Billing is a term used to describe a healthcare business operation that will make false claims that all service providers are in-network when, in fact, they knowingly know that they are not.

Where a certain percentage of the staff in the office may be approved by the patients insurance and the remainder are not.

The billing staff may put documents in front of a patient claiming that the estimates are based on the processing of their insurance as in-network, when in fact, they the provider, may be billing as out-of-network or as a cash customer. Another example is where a patient, upon arrival, may be told that their insurance was denied and then telling the Patient/Victim that they must "pay up front" when, in fact insurance was never run. this helps the healthcare provider show a significantly higher cash flow leaving the Patient/Victim to pay cash up front. The service provider runs the insurance and gets a reimbursement from the insurance company but, unless the patient checks their Explanation of Benefits religiously, they will not know that the provider has been reimbursed by the insurance company and the patient is out the cash as well.

These schemes are sometimes done while a patient is knowingly incapacitated and does not have the ability to ask questions.

Often the victim has no knowledge what has transpired until after the insurance is run and the patient gets the Explanation of Benefits, which may be as late as 60 days after the service has been provided and the Patient/Victim has paid for services not owed and has lost their rights to dispute the charges. Keep in mind that the patient has paid higher rates, thinking all along that they owed the bill, when in fact, they did not owe the bill in part or in full.

These common scams often arise from a provider sending promotional items that don't meet expectations, with victims being sold products or services they don't need.