Dr David J. Fallang,Riverview Health Institute ripoff,dishonest ,fraudelent,low downbilling Dayton Ohio

For reasons I still can't explain, this morning I held my breath, closed my eyes, and googled my own name.  Lo and behold, this "Ripoff Report" listing showed up number two on my google list.  Wow!  I didn't want to respond to this four year old trash but since it came up so high on the list I'm biting my tongue and filing this "Rebuttal" (hey, thanks a million Ripoff Report guys for the chance to respond to internet defamation that I didn't know existed for four years!)

I began my private surgical practice in 1981 so I've seen most of the changes in the insurance industry and the development of "managed health care".  It's important for any readers of this site (are there actually any?) to understand what "out of network" means.  In the old days physicians simply billed their patients and the patients paid the physicians directly (at least when they felt like paying).  When health insurance became common, physicians often sent bills directly to the insurance companies in order to spare the patients the hassle of filling out the ridiculously and intentionally complex insurance forms and thereby increase the chance of getting paid.

Insurance companies typically did not pay the entire amount billed.  Instead, each company had a data base which allowed them (or so they claimed -google "Ingenix" to learn more about the scam) to determine the "Usual, Customary, and Reasonable" fee (the "UCR" fee) for a given geographic area.  Companies usually paid only a percentage (80 percent was common) of the UCR fee.  The physician was free to bill the patient for the entire balance or to bill only for the percentage of the UCR fee that the insurance company did not pay (so you didn't have to try to explain why your fee was higher than what the insurance company thought it "should" be).

Historically, Blue Cross (Anthem) was the only company that sent checks back TO THE PATIENT and not the doctor.  The doctor then had the additional problem of trying to get paid from the patient who may have already spent the check on something else (a new TV or bass boat?).  When BC/Anthem started the "Advance Plan" back in the early 80's they offered to send checks to the physicians if they would joint the "network" and accept a "small" discount.  The discounts have grown over the years and now discounts are often 60 to 70 percent of the UCR fee (the amount actually billed has almost no importance anymore).

There are actually a number of physicians, surgical centers, and hospitals that have opted not to join these networks.  They are not bound by contracts to insurance companies and are referred to as "out-of-network" providers.  The Cleveland Clinic is one example.  Insurance companies typically charge higher premiums for "out-of-network" coverage and then pay a smaller percentage of the fees (this is NOT to be confused with payment of EMERGENCY fees to out-of-network providers which is almost alway incuded in all insurance plans anyway).  What they don't want you to know is that they pay a smaller percentage but it is a percentage of the much higher UCR amount since there is no contract to specify a discount by the provider.  Thus the actual amount paid is often HIGHER that what is paid to an in-network provider.  Many out-of-network providers either discount the copayment or forgive it completely.

The "Ripoff" reporter in this case recieved a $25,000 check from the insurance company (almost certainly Anthem).  This amount represents what THEY determined to be the UCR (remember, Usual, Customary, and REASONABLE!).  In fact, the insurance check actually represents only a percentage of the UCR amount since most insurance contracts leave a percentage of the fee to be paid by the insured (the "co-payment") and pay a lower percentage to out-of-network providers that to in-network providers. 

What "Harry" did was to decide on his own simply to keep five grand due to "issues".  In other words, Harry STOLE money that belonged to me!  He clearly states that he had every intention of keeping the money for himself until the insurance company claimed they wanted 19K back (another very common insurance company scam).

Harry also forgot to mention that we agreed to accept the insurance payment (NOT the amount that Harry felt like giving over to us after he kept what he wanted) as payment in full with no co-payment due from him.  So Harry came out better off than if he had gone to an in-network provider (and had to pay the admittedly smaller co-payment) but that still wasn't good enough for him.  He wanted to make a profit. 

BTW, $25K is vastly higher than the surgical fee and almost certainly represents the charges from the out of network HOSPITAL, not my fees.  Harry's not very forthcoming with actual facts, and most likely sent the check back to the hospital and not to me (but I AM a part owner of the hospital similar to many other surgeons). 

So where's the "ripoff" here?  First Harry rips me and/or the hospital off and then has the gall to b***h about it.  Then there's this d**n site that allows Harry to remain anonymous but publishes my name high, wide, and handsome so that the uninformed think I'm some kind of crook.  A curse on both of them.   

I have worked with health insurance for years.

Here are a few key points that will influence the outcome of your case

Number 1

Why did you choose an out of network provider?
Did he or she offer some service not available in your network?

If he offered a service not available in-network, you may have an appeal basis with your insurance company to force them to pay at the in-network rate. There is a time limit. Don't let it expire or you lose your appeal rights.

Number 2
What was his original charge?
Was it $25,000?

You must remember that the contract is between you and your doctor, especially if he or she does not contract with your insurance company. The doctor's charge is not regulated by your insurance.

He is free to charge whatever he wants and you are responsible for the entire charge.

This is the main reason a person going outside their insurance company network should use extreme caution when contracting for non-emergency medical services.

You are responsible for his entire charge unless he agrees to write off some of the charge out of the goodness of his heart.

Number 3
Although I am not a lawyer, I don't think your doctor is obligated to return any funds paid to him as long as any part of your bill remains unpaid.

Number 4
All of the above is invalid if you are on Medicare or enrolled in a Medicare HMO.

Based on your information this doesn't sound like the case.

Number 5
There seems to be a significant difference in your insurance company payment and the charge from the doctor. This is probably why the doctor is not an in-network provider.