Illegal Medical Billing Practices May Overcharge for Drugs, Procedures

If you are a California resident with a PPO insurance plan, you might have been a victim of illegal medical billing practices.

You might not even realize you have been overcharged within the last three years for prescription drugs or covered procedures. Illegal medical billing practices may benefit the pharmacy, the healthcare facility, or the insurance company.

In California, patients might be paying co-payments that are more than ten times the price that customers without insurance would be charged for the same medication. Many insurance companies charge co-pays based on drug tiers. For example, tier 1 might consist of generic drugs that normally cost anywhere from $1 to $10 for a 30-day supply for someone without insurance; but the insurance company might determine all tier 1 drugs are $20 for a 30-day supply.

Researchers looking into these situations have determined the price between the patient’s co-payment and the amount an insurer actually pays for the drug results in a “claw back” amount of money that the pharmacies keep for themselves most of the time.

For example, patient Lois R. didn’t have insurance for one month while she was between jobs. She says she had an asthma problem, so her doctor called in 10 pills of generic prednisone. Without insurance, she paid $4.61 for the prescription.

Six months later when she experienced fall allergies, she felt lucky she had insurance through her new employer by then. She had the 10-pill supply of prednisone refilled at the same pharmacy, which charged her $20. Lois was told the drug was covered by the insurance’s lowest available co-pay amount, which was $20.

Presumably, the pharmacy was allowed to keep all or part of the $15.39 difference.

Illegal Medical Billing Practices Can Leave Patients Overcharged

Even patients who have done their homework and make sure they are going to an in-network hospital can become unwary victims of illegal medical billing practices.

One family took their son to have a sinus surgery at a California hospital. The family had health insurance, but out of curiosity, asked how much they would have had to pay if they did not have insurance. The intake specialist candidly told the parents that people without insurance are charged one-third of the cost that people with insurance pay.

Due to deductibles, the family ended up having to pay almost one-third of the cost of the insurance price, which means they paid nearly what someone without insurance pays.

“We pay insurance premiums so we have the peace of mind we are covered if anything like this surgery is needed. When you consider how much we pay per month for coverage and how much we had to pay in deductibles, I think a person without insurance gets the better deal,” said Jill N., the patient’s mother.

If you live in California, are insured through a PPO plan, and believe you have been overcharged for medication or a procedure in the last three years, you could be eligible to participate in this investigation into illegal medical billing practices.

Join a Free Unfair Medical Billing Class Action Lawsuit Investigation

If you have a PPO insurance plan in California and have (i) paid a co-pay for generic prescription drugs at Rite Aid, or another retail pharmacy; or (ii) paid a higher-than-expected deductible for a covered medical procedure, you may be qualified to participate in this class action investigation.

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