Is this just unethical or downright malpractice?

S

solitaire

New Member
Jurisdiction
Oregon
If a healthcare provider claims that they are "IN NETWORK" prior to a patient getting service and later after the service reveals they weren't, is that malpractice?

For clarity (you may already know this):
IN NETWORK means Dentist has already agreed to a pre-set rates and coverages as prescribed by the Insurance company.
OUT of NETWORK means ... rates are not negotiated and patients pay the difference plus coverages are usually not 100% (far less than in network coverages)

If healthcare provider lies (about their insurance status) to get a patient to come in for a service, I think we all can agree, it is unethical at best.
But is it also "malpractice"?
If the lie is captured in writing, is that sufficient evidence to get a judge to rule it as malpractice?
 
solitaire said:
If a healthcare provider claims that they are "IN NETWORK" prior to a patient getting service and later after the service reveals they weren't, is that malpractice?

For clarity (you may already know this):
IN NETWORK means Dentist has already agreed to a pre-set rates and coverages as prescribed by the Insurance company.
OUT of NETWORK means ... rates are not negotiated and patients pay the difference plus coverages are usually not 100% (far less than in network coverages)

If healthcare provider lies (about their insurance status) to get a patient to come in for a service, I think we all can agree, it is unethical at best.
But is it also "malpractice"?
If the lie is captured in writing, is that sufficient evidence to get a judge to rule it as malpractice?
Click to expand...
Did you check with your insurance to see if this dentist was in-network? You do realize that it is your responsibility to confirm that your doctor/dentist are in network...right?
 
Yes. I did. As per insurance they were not in network just prior to service date (they were IN before and surprisingly got dropped). So, I called and asked the provider about it prior to service date.

Provider replied saying, it is just an administrative mistake and it will be fixed soon.
They also said in writing.. "This should not affect your appointment or payment."
I've been their patient for more than 10 years, I had no reason to doubt their words.
 
solitaire said:
If healthcare provider lies (about their insurance status) to get a patient to come in for a service, I think we all can agree, it is unethical at best.
But is it also "malpractice"?
If the lie is captured in writing, is that sufficient evidence to get a judge to rule it as malpractice?
Click to expand...

It is not malpractice. Malpractice is delivering professional services that fall below the minimal accepted standards of practice for that profession. How much you paid for the service is not a malpractice issue.

This is, instead, a contract law matter. Don't automatically assume the doctor lied about the insurance coverage. Insurance coverages are complex and it's quite possible for a doctor to think a particular insurer covers it when it doesn't, especially when dealing with multiple insurers.

Whether you have a good detrimental reliance defense depends on the case law (court decisions) in your state. If it's the doctor suing you, then a defense of detrimental reliance might fail, some states hold that you have the responsibility to verify the coverage yourself and if you didn't do that, you're out-of-luck. If you did contact the insurance company and it told you it was covered as in network, then you may have a good claim to sue the insurance company to have them pay you an amount that restores you to the position you'd have been in had the procedure actually been covered.
 

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