Suggestions on fraudulent medical bill

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bayview
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Re: Suggestions on fraudulent medical bill

Post by bayview » Thu Jun 06, 2019 10:44 pm

southerndoc wrote:
Thu Jun 06, 2019 10:28 pm
Oddly enough, patients seen by a resident physician must be seen by an attending physician but patients seen by NP/PA's aren't required by a national accreditation body to be seen by an attending physician. The requirement that attendings see patients seen by residents is part of resident supervision as required by the Residency Review Committees of the American Council on Graduate Medical Education, the board that grants accreditation for residency training programs.

I work in a hospital where a patient who is a level 4 or 5 Emergency Severity Index (lowest levels) may be seen by an NP/PA without a physician seeing the patient. Any level 1-3 seen by an NP/PA must be seen by an attending physician by health system guidelines. This isn't a national standard though. NP's/PA's rarely see level 1's (critical patients), but level 2's (chest pains, high-risk abdominal pains, abnormal vitals signs, etc.) can be seen by NP/PA's. They mainly see level 3-5 patients.
Oh, that's fun! So the Emergency Severity Index works in reverse order of severity with the 9928x CPT codes. What is not to love about American healthcare finance!

And I agree - residents must use the GR/GP modifier; and sometimes APs do or don't (haven't figured that one out yet as to who does and when; I worked for the VA, and we didn't bill them with modifiers.)

--random aside - hat tip and grateful appreciation to ED docs who do the medical triaging. You guys see a little bit of everything.
The continuous execution of a sound strategy gives you the benefit of the strategy. That's what it's all about. --Rick Ferri

bayview
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Re: Suggestions on fraudulent medical bill

Post by bayview » Thu Jun 06, 2019 10:47 pm

SevenBridgesRoad wrote:
Thu Jun 06, 2019 10:41 pm
bayview wrote:
Thu Jun 06, 2019 9:28 pm

If you were truly not seen/examined by anyone other than an ED physician before the hospitalist strolled in, then yes, the hospitalist should not be mooching off the ED doc’s work and billing an inpatient admit code. You’ve done what you could. If you’re not paying out of pocket, let it go. You’ve alerted your insurance to a possible problem, and it’s up to them to follow it in the future as they see fit.
Its posts like this and a few others that remind me how different we all are. And it's good to get different perspectives, so cool.

On the other hand, when I read about the stonewalling that our Topic Author is getting, it makes me want to dig further. When I'm told to move along, there's nothing to see here...it serves to motivate me even more. And don't doubt it at this point: this looks like a hospital with either super unmodern (is that a word?) compliant processes or you are being told to go away. You may not be up for the fight, but man, this would fire me up to keep going.

I'm not saying there is a big problem with this hospital, but it does happen. Google the story of the Triad hospital in Redding, CA.

Do you have a trusted physician on the medical staff who could help you navigate the system? It's extremely unusual for a Patient Advocate to blow off a patient. Ask for a face to face meeting. Use your best manners. If you attack, there could be defensiveness. Use the approach of "I'm just trying to understand."

Consider contacting the Medical Board in your state. Again, don't go in guns blazing. You have a situation and you want to understand the details, and don't feel like the hospital is taking you seriously.

It's likely the ER group is a pivate practice. Ask to meet with their medical director. Again, be super nice. Get people on your side...you're just trying to get the facts of what happened.

Try going up a level at your insurer. Is your insurance through your employer? Ask the right person in your Benefits area what to do.

Again, people are different. It doesn't make me right and them wrong. But I would pursue, even knowing it's not the dollar amount anymore.
I hear you. I worked the compliance end of documentation and coding for years. It made me crazy enough that I finally resigned, as my perfectionism couldn't deal with the inertia. (Fortunately for what was left of my sanity, the VA bills fewer than 10% of our patients, due to not billing MCare/MCaid and service-connected issues.) Props to those who fight the system. After 20 years, I had to pack it in.
The continuous execution of a sound strategy gives you the benefit of the strategy. That's what it's all about. --Rick Ferri

helloeveryone
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Re: Suggestions on fraudulent medical bill

Post by helloeveryone » Thu Jun 06, 2019 10:57 pm

SevenBridgesRoad wrote:
Thu Jun 06, 2019 10:41 pm
bayview wrote:
Thu Jun 06, 2019 9:28 pm

If you were truly not seen/examined by anyone other than an ED physician before the hospitalist strolled in, then yes, the hospitalist should not be mooching off the ED doc’s work and billing an inpatient admit code. You’ve done what you could. If you’re not paying out of pocket, let it go. You’ve alerted your insurance to a possible problem, and it’s up to them to follow it in the future as they see fit.
Its posts like this and a few others that remind me how different we all are. And it's good to get different perspectives, so cool.

On the other hand, when I read about the stonewalling that our Topic Author is getting, it makes me want to dig further. When I'm told to move along, there's nothing to see here...it serves to motivate me even more. And don't doubt it at this point: this looks like a hospital with either super unmodern (is that a word?) compliant processes or you are being told to go away. You may not be up for the fight, but man, this would fire me up to keep going.

I'm not saying there is a big problem with this hospital, but it does happen. Google the story of the Triad hospital in Redding, CA.

Do you have a trusted physician on the medical staff who could help you navigate the system? It's extremely unusual for a Patient Advocate to blow off a patient. Ask for a face to face meeting. Use your best manners. If you attack, there could be defensiveness. Use the approach of "I'm just trying to understand."

Consider contacting the Medical Board in your state. Again, don't go in guns blazing. You have a situation and you want to understand the details, and don't feel like the hospital is taking you seriously.

It's likely the ER group is a private practice. Ask to meet with their medical director. Again, be super nice. Get people on your side...you're just trying to get the facts of what happened.

Try going up a level at your insurer. Is your insurance through your employer? Ask the right person in your Benefits area what to do.

Again, people are different. It doesn't make me right and them wrong. But I would pursue, even knowing it's not the dollar amount anymore.
I think the state medical board since you have tried addressing at the local level with no resolution. Esp. if you feel that strongly about it, you can just refer it to them as “i am concerned that dr. so and so is demonstrating unethical behavior by submitting a claim for “x” level despite being certain that your physical exam consisted of the physician just doing an eyeball exam”. at a minimum it gets back to the physician that their documentation is reliant on an electronic note and they better start paying attention to that, or if they are truly unethical you are the one that helps put that in check. or if they have been reported several times your case ends up being more data for them to consider.

scorcher31
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Re: Suggestions on fraudulent medical bill

Post by scorcher31 » Thu Jun 06, 2019 10:58 pm

SevenBridgesRoad wrote:
Thu Jun 06, 2019 10:41 pm
bayview wrote:
Thu Jun 06, 2019 9:28 pm

If you were truly not seen/examined by anyone other than an ED physician before the hospitalist strolled in, then yes, the hospitalist should not be mooching off the ED doc’s work and billing an inpatient admit code. You’ve done what you could. If you’re not paying out of pocket, let it go. You’ve alerted your insurance to a possible problem, and it’s up to them to follow it in the future as they see fit.
Its posts like this and a few others that remind me how different we all are. And it's good to get different perspectives, so cool.

On the other hand, when I read about the stonewalling that our Topic Author is getting, it makes me want to dig further. When I'm told to move along, there's nothing to see here...it serves to motivate me even more. And don't doubt it at this point: this looks like a hospital with either super unmodern (is that a word?) compliant processes or you are being told to go away. You may not be up for the fight, but man, this would fire me up to keep going.

I'm not saying there is a big problem with this hospital, but it does happen. Google the story of the Triad hospital in Redding, CA.

Do you have a trusted physician on the medical staff who could help you navigate the system? It's extremely unusual for a Patient Advocate to blow off a patient. Ask for a face to face meeting. Use your best manners. If you attack, there could be defensiveness. Use the approach of "I'm just trying to understand."

Consider contacting the Medical Board in your state. Again, don't go in guns blazing. You have a situation and you want to understand the details, and don't feel like the hospital is taking you seriously.

It's likely the ER group is a private practice. Ask to meet with their medical director. Again, be super nice. Get people on your side...you're just trying to get the facts of what happened.

Try going up a level at your insurer. Is your insurance through your employer? Ask the right person in your Benefits area what to do.

Again, people are different. It doesn't make me right and them wrong. But I would pursue, even knowing it's not the dollar amount anymore.
The patient advocate is a a hospital employee. Yes they want to make the patients hospital, but they will always protect the hospital in the end. If the doctor claims he did the work, there is not going to be a way to prove otherwise in this situation. That's why the big scandals you here are based on things like double billing, or patterns of inappropriate tests/treatments etc. Insurance would be the way to go in the opinion.

If you feel strongly about it by all means go for it on all fronts, but it's very unlikely you are going to get a true resolution here you feel good about. You might get your money back but it won't be worth your time. On a more emotional level though, the doctor is unlikely to admit fault and is unlikely to receive any actions from the board or insurance company as there won't be enough evidence. Even if something occurs from it 5 years down the road due to multiple reports you won't be notified of it.

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Calli114
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Re: Suggestions on fraudulent medical bill

Post by Calli114 » Thu Jun 06, 2019 11:14 pm

SevenBridgesRoad wrote:
Thu Jun 06, 2019 10:41 pm

Do you have a trusted physician on the medical staff who could help you navigate the system? It's extremely unusual for a Patient Advocate to blow off a patient. Ask for a face to face meeting. Use your best manners. If you attack, there could be defensiveness. Use the approach of "I'm just trying to understand."

Consider contacting the Medical Board in your state. Again, don't go in guns blazing. You have a situation and you want to understand the details, and don't feel like the hospital is taking you seriously.

It's likely the ER group is a private practice. Ask to meet with their medical director. Again, be super nice. Get people on your side...you're just trying to get the facts of what happened.

Try going up a level at your insurer. Is your insurance through your employer? Ask the right person in your Benefits area what to do.

Again, people are different. It doesn't make me right and them wrong. But I would pursue, even knowing it's not the dollar amount anymore.
Don't know any physicians on staff, and it's an ACA policy so I don't have an employer.
The hospitalists' office would never give me a name or put me through to a medical director, in fact they answered no questions and had the Patient Advocate office call me, so there was avoidance from the get-go.

I will try a different division of the insurance company to see if they accept concerns like this, thx.

[edited to fix broken quotes - moderator prudent]

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southerndoc
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Re: Suggestions on fraudulent medical bill

Post by southerndoc » Thu Jun 06, 2019 11:25 pm

PM me the facility and I may can find the medical director for you.

I'm assuming you want to meet with the hospitalist medical director and not the ED medical director since it seems the hospitalist service is the one in question.

I would refrain from contacting the medical board. All it will do is trigger an investigation where they request the records, possibly interview the doc, do a he said/she said, and probably ultimately side with the doc. Will be a waste of time for you, a waste of time for those involved at the state medical board, and will unlikely change the behavior of the doc.

jacoavlu
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Re: Suggestions on fraudulent medical bill

Post by jacoavlu » Thu Jun 06, 2019 11:28 pm

Just a few thoughts from another doc

It’s wrong for a doc to document doing something they didn’t actually do.

But the doc may very well have zero to do with the billing and coding. Many (most?) docs don’t really have a direct line to what is coded and ultimately billed. They document, and then the billing and coding people read the document and decide what to bill and code.

They may get some education around the process, as in it’s really important to document xyz when you do this or that, but I’d bet money that it’s not some conscious decision on the part of the hospitalist to bill you for a Level 2.

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southerndoc
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Re: Suggestions on fraudulent medical bill

Post by southerndoc » Thu Jun 06, 2019 11:29 pm

I think his issue was the doc documented things in the exam that weren't examined. An exam that wasn't performed as documented caused upcoding of the chart by the coders.

jacoavlu
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Re: Suggestions on fraudulent medical bill

Post by jacoavlu » Thu Jun 06, 2019 11:34 pm

Understood. That’s different than “I waited on the bill, and sure enough he charged me for a Level 2 H&P“

bayview
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Re: Suggestions on fraudulent medical bill

Post by bayview » Thu Jun 06, 2019 11:41 pm

southerndoc wrote:
Thu Jun 06, 2019 11:29 pm
I think his issue was the doc documented things in the exam that weren't examined. An exam that wasn't performed as documented caused upcoding of the chart by the coders.
It would be interesting to know if the coding and billing functions were separate, or if everything were done by "coder/billers."

My professional organization (AHIMA) says it's unethical for the two functions to be combined, as coding should be (ideally) separate from billing, but stuff happens.
The continuous execution of a sound strategy gives you the benefit of the strategy. That's what it's all about. --Rick Ferri

jacoavlu
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Re: Suggestions on fraudulent medical bill

Post by jacoavlu » Thu Jun 06, 2019 11:43 pm

^^^
see, proves my point - I’m a doc and I don’t even know if it’s two people or one!

sawhorse
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Re: Suggestions on fraudulent medical bill

Post by sawhorse » Thu Jun 06, 2019 11:55 pm

bayview wrote:
Thu Jun 06, 2019 11:41 pm
southerndoc wrote:
Thu Jun 06, 2019 11:29 pm
I think his issue was the doc documented things in the exam that weren't examined. An exam that wasn't performed as documented caused upcoding of the chart by the coders.
It would be interesting to know if the coding and billing functions were separate, or if everything were done by "coder/billers."

My professional organization (AHIMA) says it's unethical for the two functions to be combined, as coding should be (ideally) separate from billing, but stuff happens.
A hospitalist told me that the billing department routinely asks her if they can bill for something higher than what she indicated. In one case she gave a child a dose of albuterol for something other than asthma. I'm not a doctor so I don't know what it might have been used for, but she told me that the child didn't have asthma.

The billing office asked if they could code for exacerbation of asthma (or something like that). The doctor said no. Later she found out that the billing department upcoded anyway against her permission.

bayview
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Re: Suggestions on fraudulent medical bill

Post by bayview » Thu Jun 06, 2019 11:59 pm

jacoavlu wrote:
Thu Jun 06, 2019 11:43 pm
^^^
see, proves my point - I’m a doc and I don’t even know if it’s two people or one!
Exactly!

I was one of those reviled (lol) documentation improvement specialists, and it was such fun trying to explain to clinicians how their EMR notes which were perfectly understandable by their colleagues went 270 degrees wrong when analyzed by coders, who are constrained by coding rules rather than by clinical understanding and common sense.

It's really tragic how healthcare in the US has been impacted by third-party insurers. (I'll step back from the abyss now.)

--oh, btw, please don't ever document "urosepsis" or (God help us) "pneumosepsis". Thanks in advance from those who have to extract data from notes and turn them into diagnostic and procedural codes. :D
The continuous execution of a sound strategy gives you the benefit of the strategy. That's what it's all about. --Rick Ferri

bayview
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Re: Suggestions on fraudulent medical bill

Post by bayview » Fri Jun 07, 2019 12:03 am

sawhorse wrote:
Thu Jun 06, 2019 11:55 pm
bayview wrote:
Thu Jun 06, 2019 11:41 pm
southerndoc wrote:
Thu Jun 06, 2019 11:29 pm
I think his issue was the doc documented things in the exam that weren't examined. An exam that wasn't performed as documented caused upcoding of the chart by the coders.
It would be interesting to know if the coding and billing functions were separate, or if everything were done by "coder/billers."

My professional organization (AHIMA) says it's unethical for the two functions to be combined, as coding should be (ideally) separate from billing, but stuff happens.
A hospitalist told me that the billing department routinely asks her if they can bill for something higher than what she indicated. In one case she gave a child a dose of albuterol for something other than asthma. I'm not a doctor so I don't know what it might have been used for, but she told me that the child didn't have asthma.

The billing office asked if they could code for exacerbation of asthma (or something like that). The doctor said no. Later she found out that the billing department upcoded anyway against her permission.
And that is so wrong, wrong, wrong. You can only * ethically and legally * submit diagnostic and procedural codes that are supported by the documentation in the clinical record.

This is exactly what I meant when I posted above that coding and billing should be separate entities. Billers have no business whatsoever in entering or editing codes.

The role of coding is to capture diagnoses and procedures for the database. This is how we know what is going on, and how we treat it.

When codes are altered by the business department (billing), the data is corrupted, and everything goes to hell in terms of knowledge and research. This is NOT how healthcare should be conducted. Lying for reimbursement is so, so wrong.
Last edited by bayview on Fri Jun 07, 2019 12:04 am, edited 1 time in total.
The continuous execution of a sound strategy gives you the benefit of the strategy. That's what it's all about. --Rick Ferri

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SevenBridgesRoad
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Re: Suggestions on fraudulent medical bill

Post by SevenBridgesRoad » Fri Jun 07, 2019 12:04 am

jacoavlu wrote:
Thu Jun 06, 2019 11:34 pm
Understood. That’s different than “I waited on the bill, and sure enough he charged me for a Level 2 H&P“
Here's the problem, quote "And left with taking any verbal history or doing ANY exam; the guy stood with his arms crossed the whole time and didn't get within 5 feet of me."

It's true the coders may be the problem. All the more reason to get to the bottom of your inquiry. It may be the coders who are creating an dangerous situation for the docs and hospital. The medical directors should be interested. Its the physicians who are ultimately legally responsible for the codes submitted in their name.

And the reason I mentioned the ER Med Director is she/he will probably not be a hospital employee and might be more than willing to hook you into the right parts of the system and perhaps partner with you if you approach this right.

But...Perhaps the CEO leads a culture of fear, instead of one based on patient first and legal compliance. Perhaps the Patient Advocate doesn't take his/her job seriously and is scared of the CEO. Perhaps the board is old-fashioned and not fully engaged as a modern hospital board. Perhaps the Medical Board in your state doesn't pursue concerns vigorouly. But I can say, I've been a part of health systems with CEOs seriously leading a culture of safety and patients first and compliance (I was such a CEO BTW). I've seen boards fully engaged, attending national conferences to learn their awesome responsibilities in the modern legal environment and holding the CEO and physician leaders accountable. I've seen Patient Advocate offices who took their jobs seriously and felt supported by the CEO to do the right thing for patients. (I had the Patient Advocate report directly to the Board quarterly (I left the room, just like for the Auditors final report) and I insisted she speak the truth.) I've seen solid medical directors who are true leaders and not solely protectors of troublesome docs, who understand physician coding and who perform performance reviews for improvment. I could go on. So not all hospitals are living in the 1980's, but I'm sure there are some left.

Be are part of the process to make things better.
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sawhorse
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Re: Suggestions on fraudulent medical bill

Post by sawhorse » Fri Jun 07, 2019 2:29 am

bayview wrote:
Fri Jun 07, 2019 12:03 am
And that is so wrong, wrong, wrong. You can only * ethically and legally * submit diagnostic and procedural codes that are supported by the documentation in the clinical record.

This is exactly what I meant when I posted above that coding and billing should be separate entities. Billers have no business whatsoever in entering or editing codes.

The role of coding is to capture diagnoses and procedures for the database. This is how we know what is going on, and how we treat it.

When codes are altered by the business department (billing), the data is corrupted, and everything goes to hell in terms of knowledge and research. This is NOT how healthcare should be conducted. Lying for reimbursement is so, so wrong.
If billing and coding were separate, wouldn't a greedy hospital just train the coders in what codes are more lucrative and put pressure on them to code higher?

bayview
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Re: Suggestions on fraudulent medical bill

Post by bayview » Fri Jun 07, 2019 7:45 am

sawhorse wrote:
Fri Jun 07, 2019 2:29 am
bayview wrote:
Fri Jun 07, 2019 12:03 am
And that is so wrong, wrong, wrong. You can only * ethically and legally * submit diagnostic and procedural codes that are supported by the documentation in the clinical record.

This is exactly what I meant when I posted above that coding and billing should be separate entities. Billers have no business whatsoever in entering or editing codes.

The role of coding is to capture diagnoses and procedures for the database. This is how we know what is going on, and how we treat it.

When codes are altered by the business department (billing), the data is corrupted, and everything goes to hell in terms of knowledge and research. This is NOT how healthcare should be conducted. Lying for reimbursement is so, so wrong.
If billing and coding were separate, wouldn't a greedy hospital just train the coders in what codes are more lucrative and put pressure on them to code higher?
Sure, that happens. But there is a compliance officer who is * supposed * to watch for such things.

The truly effective counter is that coders or others can go whistleblower. That’s what happened at several CA hospitals, all owned by the same physician, where providers were pressured to document kwashiorkor instead of more common levels of malnutrition. The coders knew the patients didn’t meet the diagnostic criteria for kwashiorkor, complained, and when they were ignored, took it public. (Coders are supposed to understand enough about clinical conditions to request clarification when notes are inconsistent or unclear: sepsis vs bacteremia, acute encephalopathy vs delirium, etc.)

Good coders don’t want to get on Medicare’s fecal chart!
The continuous execution of a sound strategy gives you the benefit of the strategy. That's what it's all about. --Rick Ferri

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Calli114
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Re: Suggestions on fraudulent medical bill

Post by Calli114 » Fri Jun 07, 2019 9:31 am

southerndoc wrote:
Thu Jun 06, 2019 11:25 pm
PM me the facility and I may can find the medical director for you.

I'm assuming you want to meet with the hospitalist medical director and not the ED medical director since it seems the hospitalist service is the one in question.
I think I found it online, and a VP of Corporate Integrity, which sounds as if that would be the way to go above the Patient Advocate Dept.

EnjoyIt
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Re: Suggestions on fraudulent medical bill

Post by EnjoyIt » Fri Jun 07, 2019 2:26 pm

I am not condoning what happened, but I will shed some light into it.

Over the last few decades different organizations starting with CMS have told us how and what we need to document. Much of the things documented in the chart these days add nothing to patient care but take significant time to do. As an example if someone is having a stroke, an examination of their skin will likely add nothing to the patient’s care, but is still added and done because CMS declares that X items must be documented for billing purposes. On top of that hospital compliance officers and safety teams add more documentation requirements so that they can audit charts easier or maybe feel that somehow documenting an extra line may add value. Sometimes it does while other times it adds nothing but time spent documenting. The overarching demand of useless documentation has forced physicians to hire scribes to help them keep up.

Most physicians are ck and tired of this documentation creep that slowly adds more and more every few months and have created templates to make sure they don’t miss what every entity demands of them. This is very likely What happened here.

Eventually I suspect and hope doctors will grow a pair and retaliate against all that they are forced to do that adds no patient value.

Next, believe it or not, one can manage a patient properly and never do a physical exam on that patient. I am not talking about billing. I am simply discussing patient care. For example if a patient is admitted for diverticulitis with micro perforation colitis diagnosed by the ER doctor with the help of the CT, the patient is placed on abx and a general surgeon to consult while admitted by a Hospitalist. If they get better they discharged otherwise the surgeon will operate. On admission if everything is accurate a repeat physical exam by the Hospitalist will add nothing to this process. Again, I’m not condoning not doing a physical exam, I am just explaining some facts.

I ask you this? Did the doctor properly take care of you on admission? Did you get the right treatment? Do you think pulling out a stethoscope and listening to your heart and lungs, pushing on your neck for lymph nodes and doing a neurological exam would have changed your care?

Yes, this doctor should have examined you and documented accurately what he examined. But again, I just wanted to lay out some facts for you.

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SevenBridgesRoad
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Re: Suggestions on fraudulent medical bill

Post by SevenBridgesRoad » Fri Jun 07, 2019 8:22 pm

EnjoyIt wrote:
Fri Jun 07, 2019 2:26 pm
I am not condoning what happened, but I will shed some light into it.

Over the last few decades different organizations starting with CMS have told us how and what we need to document. Much of the things documented in the chart these days add nothing to patient care but take significant time to do. As an example if someone is having a stroke, an examination of their skin will likely add nothing to the patient’s care, but is still added and done because CMS declares that X items must be documented for billing purposes. On top of that hospital compliance officers and safety teams add more documentation requirements so that they can audit charts easier or maybe feel that somehow documenting an extra line may add value. Sometimes it does while other times it adds nothing but time spent documenting. The overarching demand of useless documentation has forced physicians to hire scribes to help them keep up.

Most physicians are ck and tired of this documentation creep that slowly adds more and more every few months and have created templates to make sure they don’t miss what every entity demands of them. This is very likely What happened here.

Eventually I suspect and hope doctors will grow a pair and retaliate against all that they are forced to do that adds no patient value.

Next, believe it or not, one can manage a patient properly and never do a physical exam on that patient. I am not talking about billing. I am simply discussing patient care. For example if a patient is admitted for diverticulitis with micro perforation colitis diagnosed by the ER doctor with the help of the CT, the patient is placed on abx and a general surgeon to consult while admitted by a Hospitalist. If they get better they discharged otherwise the surgeon will operate. On admission if everything is accurate a repeat physical exam by the Hospitalist will add nothing to this process. Again, I’m not condoning not doing a physical exam, I am just explaining some facts.

I ask you this? Did the doctor properly take care of you on admission? Did you get the right treatment? Do you think pulling out a stethoscope and listening to your heart and lungs, pushing on your neck for lymph nodes and doing a neurological exam would have changed your care?

Yes, this doctor should have examined you and documented accurately what he examined. But again, I just wanted to lay out some facts for you.
Interestingly, CPT was started by the AMA and is maintained by the AMA. The docs did it to ourselves.

https://en.wikipedia.org/wiki/Current_P ... erminology

I have no argument with you re the Inside Baseball view of good clinical medicine. CPT, ICD10, Epic, etc have all added a ton of waste to the physician's workday.
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Cyanide123
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Re: Suggestions on fraudulent medical bill

Post by Cyanide123 » Fri Jun 07, 2019 9:52 pm

SevenBridgesRoad wrote:
Thu Jun 06, 2019 1:14 pm
carolinaman wrote:
Thu Jun 06, 2019 7:43 am
SevenBridgesRoad wrote:
Wed Jun 05, 2019 6:13 pm
https://emuniversity.com/Page3.html

Level 2 hospital H&P requires comprehensive exam. That can’t be done from across the room. I would challenge this.
Really! He has already appealed once and they rejected his appeal. This is for $72. Pay it and move on.
You are wrong. A physical exam cannot be done from across the room. A few elements, yes. But not the entire exam.

I can do 80 percent of my physical exam by mostly just looking at the patient. You need I believe 2-4 systems for a lower level billing on exam, and 4 or more for higher level.

Literally when I walk in the room I could come out and chart at least 4 physical exam systems without putting hands on the patient, and none of this would be fraudulent because you get a lot of info by just seeing a patient:

General: no acute distress. Breathing comfortably, speaking in full sentences
Head: normocephalic, atraumatic
Eyes: extra ocular movements intact (assuming the person looks around a little), no scleral icterus
Neck: symmetric appearing
Resp: no respiratory distress, breathing comfortably, no visible retractions
Cardiac: normal rate and rhythym (by just glancing at the monitor you can usual tell those)
Abd: non distended
Skin: no rashes, redness over exposed areas
Extremities (if you're in a gown you should be able to see them): no obvious swelling visualized
Neuro: alert, answering questions appropriately, moving upper and lower extremities grossly without obvious motor deficits, normal speech, no dysarthria, slurring of words, speaking in full sentences. No facial droop, normal extra ocular movements, hearing appears to be intact
Psych: no anxiety, speech normal, non pressured,. Normal affect.

There you go... Every finding on that exam is visual or something you get from talking to a person. That is 9 different systems and it will qualify for the highest level of billing and didn't even require a person putting hands on a patient.


The few things I can add by putting my hands on the patient:
Abd: soft, no tenderness on exam, no rigidity or peritoneal signs
Cardiac: no rubs murmurs gallops
Resp: no wheezing, rales or rhonchi
Exts: no calf tenderness


I mean yeah you can go into detailed neuro exams, look in the mouth and ears etc - but depends on chief complaint. Most physicians will hear lungs, heart and press on the belly. And literally those are the 3-4 things they add to their exam by putting their hands on the patient. I would argue that an experienced physician could tell a lot just by looking at a patient. Of course now if you didn't hear the heart or lungs and then charted it, then that's fraud.

Turbo29
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Re: Suggestions on fraudulent medical bill

Post by Turbo29 » Fri Jun 07, 2019 10:12 pm

I had a cortisone shot coded on my doctor visit bill once. I contacted the office several times and told them I received no injection of any kind during my visit but could never get it removed. I never had mis-billing at that office prior nor since. I have finally come to believe it was just a mistake. The dollar amount was very low and probably what should have been coded instead cost as much or more so I just let it go.

toofache32
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Re: Suggestions on fraudulent medical bill

Post by toofache32 » Fri Jun 07, 2019 10:15 pm

Turbo29 wrote:
Fri Jun 07, 2019 10:12 pm
I had a cortisone shot coded on my doctor visit bill once. I contacted the office several times and told them I received no injection of any kind during my visit but could never get it removed. I never had mis-billing at that office prior nor since. I have finally come to believe it was just a mistake. The dollar amount was very low and probably what should have been coded instead cost as much or more so I just let it go.
Transpose one digit in the 5-digit CPT code and you have a completely different treatment.

Tachyon
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Re: Suggestions on fraudulent medical bill

Post by Tachyon » Fri Jun 07, 2019 10:23 pm

Calli114 wrote:
Wed Jun 05, 2019 5:16 pm
I had a hospital admission in April during which the admitting hospitalist physician came into my ER room, said "Hi, I'm Dr. Smith. We'll be admitting you for XYZ, you'll probably be here 2 or 3 days, OK?" And left with taking any verbal history or doing ANY exam; the guy stood with his arms crossed the whole time and didn't get within 5 feet of me.

I never saw him again, as another Dr took over the next day, so I was surprised to see on the patient electronic portal that Dr. XYZ had entered an entire History and Physical document.
I waited on the bill, and sure enough he charged me for a Level 2 H&P after not doing either history or exam. The insurance had already paid, so my portion is $72.

Today I got a letter that the hospital has rejected my grievance after "reviewing documentation and talking to staff." So I guess they have reviewed a completely fraudulent document, to determine there was no fraud. I had no one with me, so am afraid this is coming down to a He said/She said situation. It's a small amount of money but has me riled up because it's wrong.

I haven't yet paid the bill, so I don't know if I can take them to small claims court and assume they won't show up, or if I would have to pay it off and then do that.
Meanwhile, I guess I will call the Patient Advocate and emphasize they are basing their decision on fraudulent documentation.
I read through the posts. Being a frugal person myself, I would've chased what I figure was improper billing to get some money back. I did something similar when I took my daughter for a hearing exam, and they billed for a physician office visit as well as all the tests that the audiologists did (only the audiologist saw my daughter). The thing is, Medicare doesn't allow audiologist to bill as a physician office visit, and if the hospital accepts Medicare, then they can't selectively bill other insurance differently (I have BCBS). I was initially denied my request. I then said I'd pay the full bill, but will send a notice to the state regulators about the situation. Got a call the next day that they are waiving that charge. And so I let it go. For me, it was about the charge. I wasn't in it to "right a wrong" and see that practice is changed. I didn't really care to have an entire hospital department under scrutiny. I would've followed up and sent a notice to state regulators and then move on with my life not following up on it. For me, it was 2 phone calls.

I'm unsure of your true intent. Is it really just about the $72? Is it a matter of principle now? Has it become some personal mission? Do you wish to see this doc fired/lose license? It seems to me that if it's just about the $72, it seems you have put way too much time into this already and it's better to let it go. What's actually driving the situation?

fasteddie911
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Re: Suggestions on fraudulent medical bill

Post by fasteddie911 » Sat Jun 08, 2019 7:52 am

Accusations of fraud right of the bat are a bit much. I doubt the doctor does their own billing, so I wouldn't really blame them. I agree what others above wrote. It's not a big deal and I'd pay it and move on. Maybe it's technically incorrect, but I'm not sure of the rules regarding ER to hospitalist transfers, as it seems kind of redundant to require two H&P's for the same patient. In any case, the doctor likely got what the info he needed from the ER, lab results, etc. If he didn't he would've filled in the gaps with their own exam and questions. A lot of medicine can be done without seeing the patient. He could've easily done an "official" H&P to satisfy you and check the boxes for insurance, but it would add no value for him and just waste time. Instead his time is spent on the backend, putting in admission orders, setting things up, etc. That minute he spent with you isn't the only effort he put in, he could easily be spending an hour or more on the backend. He should get paid for that work and it is thru the admission coding. It can get tiresome for both patients and doctor to re-hash things over and over again.
Last edited by fasteddie911 on Sat Jun 08, 2019 10:32 am, edited 1 time in total.

masonstone
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Re: Suggestions on fraudulent medical bill

Post by masonstone » Sat Jun 08, 2019 8:58 am

Calli114 wrote:
Wed Jun 05, 2019 5:16 pm
I had a hospital admission in April during which the admitting hospitalist physician came into my ER room, said "Hi, I'm Dr. Smith. We'll be admitting you for XYZ, you'll probably be here 2 or 3 days, OK?" And left with taking any verbal history or doing ANY exam; the guy stood with his arms crossed the whole time and didn't get within 5 feet of me.

I never saw him again, as another Dr took over the next day, so I was surprised to see on the patient electronic portal that Dr. XYZ had entered an entire History and Physical document.
I waited on the bill, and sure enough he charged me for a Level 2 H&P after not doing either history or exam. The insurance had already paid, so my portion is $72.

Today I got a letter that the hospital has rejected my grievance after "reviewing documentation and talking to staff." So I guess they have reviewed a completely fraudulent document, to determine there was no fraud. I had no one with me, so am afraid this is coming down to a He said/She said situation. It's a small amount of money but has me riled up because it's wrong.

I haven't yet paid the bill, so I don't know if I can take them to small claims court and assume they won't show up, or if I would have to pay it off and then do that.
Meanwhile, I guess I will call the Patient Advocate and emphasize they are basing their decision on fraudulent documentation.
You don’t need to touch the patient for a level 2 exam and yes you can get the history from the chart. Sounds like you’re falsely accusing someone of fraud, which can be a liability for you.

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Calli114
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Re: Suggestions on fraudulent medical bill

Post by Calli114 » Sat Jun 08, 2019 4:40 pm

Tachyon wrote:
Fri Jun 07, 2019 10:23 pm

I'm unsure of your true intent. Is it really just about the $72? Is it a matter of principle now? Has it become some personal mission? Do you wish to see this doc fired/lose license? It seems to me that if it's just about the $72, it seems you have put way too much time into this already and it's better to let it go. What's actually driving the situation?
No I certainly don't regard it as something he should be fired over. I'm aware how much of the work can be done based on the ER note and previous records, but I resent them stonewalling and not acknowledging that there are many "hands on" parts of the exam note that he simply did not do. If he admits 10 people a day and doesn't exam a single one of them (who knows?), I don't think that's proper or fair to the payor sources who are assuming he actually does what is reflected in the note.

sawhorse
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Re: Suggestions on fraudulent medical bill

Post by sawhorse » Sat Jun 08, 2019 5:58 pm

As I've seen before on this forum, a lot of people are saying to just pay it when, if it were anything but a medical bill, they would say to fight it.

Auto body shops itemize and code with a byzantine and often nonsensical system that is not unlike hospitals. If a body shop falsely (intentionally or not) said they conducted a diagnostic test, one that was actually not really necessary to know what the real problem was, and charged $72 for it, and then stonewalled the car owner when s/he challenged it, this board would be full of people saying that you should fight it.

Body shops have people's lives in their hands too. They too deal with the problem of insurance companies trying to dictate what they do and then denying claims.

Yet I doubt there would be as many people on this board telling the car owner to just pay it and think of the underpaid and overworked laborers and shop owners.

If the patient/insurance was wrongly billed, then that should be rectified. It doesn't matter that it's a medical bill.

TropikThunder
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Re: Suggestions on fraudulent medical bill

Post by TropikThunder » Sat Jun 08, 2019 6:12 pm

sawhorse wrote:
Sat Jun 08, 2019 5:58 pm
As I've seen before on this forum, a lot of people are saying to just pay it when, if it were anything but a medical bill, they would say to fight it.

Auto body shops itemize and code with a byzantine and often nonsensical system that is not unlike hospitals. If a body shop falsely (intentionally or not) said they conducted a diagnostic test, one that was actually not really necessary to know what the real problem was, and charged $72 for it, and then stonewalled the car owner when s/he challenged it, this board would be full of people saying that you should fight it.

Body shops have people's lives in their hands too. They too deal with the problem of insurance companies trying to dictate what they do and then denying claims.

Yet I doubt there would be as many people on this board telling the car owner to just pay it and think of the underpaid and overworked laborers and shop owners.

If the patient/insurance was wrongly billed, then that should be rectified. It doesn't matter that it's a medical bill.
Just a guess, but there are probably a lot more physicians on this board than there are body shop owners ..... :|

We may well have the most technologically advanced healthcare system in the world (somewhat debatable) but our healthcare financing system is near the worst (not really debatable at all). It's been said ad nauseum, but healthcare is the one field of commerce where it is nigh on impossible to (1) find out what something will cost in advance; (2) find out what services one actually did or did not receive, and who performed them; and (3) decide if you received appropriate value.

Of course, I have no idea how to fix it ....

chessknt
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Re: Suggestions on fraudulent medical bill

Post by chessknt » Sat Jun 08, 2019 6:57 pm

sawhorse wrote:
Sat Jun 08, 2019 5:58 pm
As I've seen before on this forum, a lot of people are saying to just pay it when, if it were anything but a medical bill, they would say to fight it.

Auto body shops itemize and code with a byzantine and often nonsensical system that is not unlike hospitals. If a body shop falsely (intentionally or not) said they conducted a diagnostic test, one that was actually not really necessary to know what the real problem was, and charged $72 for it, and then stonewalled the car owner when s/he challenged it, this board would be full of people saying that you should fight it.

Body shops have people's lives in their hands too. They too deal with the problem of insurance companies trying to dictate what they do and then denying claims.

Yet I doubt there would be as many people on this board telling the car owner to just pay it and think of the underpaid and overworked laborers and shop owners.

If the patient/insurance was wrongly billed, then that should be rectified. It doesn't matter that it's a medical bill.
Auto body coding and medical decision making as captured by e/m billing are nothing alike. As mentioned above the charge isn't fraudulent since the entire exam for a level 2 note can be done without touching a patient and meet cms guidelines. If that surprises you then you aren't in the medical field. Op is riled up over a non-issue.

toofache32
Posts: 1712
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Re: Suggestions on fraudulent medical bill

Post by toofache32 » Sat Jun 08, 2019 7:15 pm

TropikThunder wrote:
Sat Jun 08, 2019 6:12 pm

but healthcare is the one field of commerce where it is nigh on impossible to (1) find out what something will cost in advance
When insurance is involved. This is an insurance problem. Insurance benefits from opaqueness.

student
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Re: Suggestions on fraudulent medical bill

Post by student » Sat Jun 08, 2019 7:58 pm

sawhorse wrote:
Sat Jun 08, 2019 5:58 pm
As I've seen before on this forum, a lot of people are saying to just pay it when, if it were anything but a medical bill, they would say to fight it.

Auto body shops itemize and code with a byzantine and often nonsensical system that is not unlike hospitals. If a body shop falsely (intentionally or not) said they conducted a diagnostic test, one that was actually not really necessary to know what the real problem was, and charged $72 for it, and then stonewalled the car owner when s/he challenged it, this board would be full of people saying that you should fight it.

Body shops have people's lives in their hands too. They too deal with the problem of insurance companies trying to dictate what they do and then denying claims.

Yet I doubt there would be as many people on this board telling the car owner to just pay it and think of the underpaid and overworked laborers and shop owners.

If the patient/insurance was wrongly billed, then that should be rectified. It doesn't matter that it's a medical bill.
I think the difference, at least to me, is the complexity of a body shop bill is no where near the complexity of a medical bill. By investing a reasonable amount of time, I can understand the one from the body shop. I don't think the same can be said for a medical bill, at least I am not smart enough to understand it in a reasonable amount of time. So the bottom line is whether the amount of money is worth investing the time to address the issue. If the amount is small, write off (and be mad about it). If the amount is sufficiently large, fight it. If the amount is very large, hire a professional. Also, judging from the responses by those in the medical field, it seems to me that no mistake was made.

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ram
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Re: Suggestions on fraudulent medical bill

Post by ram » Sat Jun 08, 2019 10:36 pm

I have only heard one side of the story and so I wont comment on this particular instance.

However for clinic follow up visits I frequently (and legitimately) bill level 2, level 3 and level 4 without coming within 5 feet of the patient. I do speak with the patient but an exam requiring touching the patient is not needed.

Frequently in the ICU no speaking with the patient is involved (patient is unconscious and/or has a breathing tube down his throat). Review of the chart and an exam are done and plan is documented. This typically results in a higher complexity visit than a level 2 admission visit by a hospitalist.
Ram

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southerndoc
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Re: Suggestions on fraudulent medical bill

Post by southerndoc » Sat Jun 08, 2019 10:46 pm

sawhorse wrote:
Sat Jun 08, 2019 5:58 pm
As I've seen before on this forum, a lot of people are saying to just pay it when, if it were anything but a medical bill, they would say to fight it.

Auto body shops itemize and code with a byzantine and often nonsensical system that is not unlike hospitals. If a body shop falsely (intentionally or not) said they conducted a diagnostic test, one that was actually not really necessary to know what the real problem was, and charged $72 for it, and then stonewalled the car owner when s/he challenged it, this board would be full of people saying that you should fight it.

Body shops have people's lives in their hands too. They too deal with the problem of insurance companies trying to dictate what they do and then denying claims.

Yet I doubt there would be as many people on this board telling the car owner to just pay it and think of the underpaid and overworked laborers and shop owners.

If the patient/insurance was wrongly billed, then that should be rectified. It doesn't matter that it's a medical bill.
Was there a diagnostic test that was falsely billed? It sounds like the bill is equivalent to the mechanic billing for his time spent thinking about what is causing the problem instead of running a diagnostic test. Lawyers do this all the time. They bill for their thoughts or communication time on the phone with a client without shaking their hand.

I think the physician in question did himself a disservice by not examining the patient and billing at a higher rate. At least the OP would be happy then.

EnjoyIt
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Re: Suggestions on fraudulent medical bill

Post by EnjoyIt » Sun Jun 09, 2019 11:22 am

southerndoc wrote:
Sat Jun 08, 2019 10:46 pm
sawhorse wrote:
Sat Jun 08, 2019 5:58 pm
As I've seen before on this forum, a lot of people are saying to just pay it when, if it were anything but a medical bill, they would say to fight it.

Auto body shops itemize and code with a byzantine and often nonsensical system that is not unlike hospitals. If a body shop falsely (intentionally or not) said they conducted a diagnostic test, one that was actually not really necessary to know what the real problem was, and charged $72 for it, and then stonewalled the car owner when s/he challenged it, this board would be full of people saying that you should fight it.

Body shops have people's lives in their hands too. They too deal with the problem of insurance companies trying to dictate what they do and then denying claims.

Yet I doubt there would be as many people on this board telling the car owner to just pay it and think of the underpaid and overworked laborers and shop owners.

If the patient/insurance was wrongly billed, then that should be rectified. It doesn't matter that it's a medical bill.
Was there a diagnostic test that was falsely billed? It sounds like the bill is equivalent to the mechanic billing for his time spent thinking about what is causing the problem instead of running a diagnostic test. Lawyers do this all the time. They bill for their thoughts or communication time on the phone with a client without shaking their hand.

I think the physician in question did himself a disservice by not examining the patient and billing at a higher rate. At least the OP would be happy then.
Yup, it sounds like the physician could have added a little more to the chart and billed for a level 3 chart. OP should be happy it was only $72.

Anyways, todays documentation requirements are a bunch of nonsense used by the insurance/CMS to find ways not to pay for services rendered while adding no benefit to the patient or patient care. This is just an example of how the doc could have spent an extra 2 minutes and billed/documented higher but adding nothing more to the patient.

bayview
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Re: Suggestions on fraudulent medical bill

Post by bayview » Sun Jun 09, 2019 5:29 pm

ram wrote:
Sat Jun 08, 2019 10:36 pm
I have only heard one side of the story and so I wont comment on this particular instance.

However for clinic follow up visits I frequently (and legitimately) bill level 2, level 3 and level 4 without coming within 5 feet of the patient. I do speak with the patient but an exam requiring touching the patient is not needed.

Frequently in the ICU no speaking with the patient is involved (patient is unconscious and/or has a breathing tube down his throat). Review of the chart and an exam are done and plan is documented. This typically results in a higher complexity visit than a level 2 admission visit by a hospitalist.
That’s because on follow-up visits (“established patients”), you only need to document two of the three elements (history, exam, medical decision-making) to support the E/M code that you assign.
The continuous execution of a sound strategy gives you the benefit of the strategy. That's what it's all about. --Rick Ferri

partner
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Re: Suggestions on fraudulent medical bill

Post by partner » Sun Jun 09, 2019 6:53 pm

It seems to me that insurance companies don't really care if they are getting ripped off. One day while looking over the claims on my insurance companies web site (my account), I noticed a claim from a doctor that I had never seen. I notified the insurance company and they said they would investigate. I tracked the claims progress and each time it progressed, I call the insurance company and repeated the story, they saw in the record that it was supposedly being investigated. Since it showed that I owned a co-pay, I called the doctors office and asked about it. Their records showed that I was not there that day and could not explain the bill. And of course I did not owe any co-pay. I gave up calling the insurance co after a while when it became clear they were not concerned about it. The last entry in the insurance company record was they had sent the dr a check. This was Aetna.

sawhorse
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Re: Suggestions on fraudulent medical bill

Post by sawhorse » Sun Jun 09, 2019 9:05 pm

partner wrote:
Sun Jun 09, 2019 6:53 pm
It seems to me that insurance companies don't really care if they are getting ripped off. One day while looking over the claims on my insurance companies web site (my account), I noticed a claim from a doctor that I had never seen. I notified the insurance company and they said they would investigate. I tracked the claims progress and each time it progressed, I call the insurance company and repeated the story, they saw in the record that it was supposedly being investigated. Since it showed that I owned a co-pay, I called the doctors office and asked about it. Their records showed that I was not there that day and could not explain the bill. And of course I did not owe any co-pay. I gave up calling the insurance co after a while when it became clear they were not concerned about it. The last entry in the insurance company record was they had sent the dr a check. This was Aetna.
I've experienced this too. I had an urgent care billed insurance twice for the same $167 swab test, and insurance paid for it twice. I notified the insurance company, and they didn't do anything about it.

It's especially puzzling because they go out of their way to deny some claims, but they'll gladly pay for some claims that they have been told are false.

toofache32
Posts: 1712
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Re: Suggestions on fraudulent medical bill

Post by toofache32 » Sun Jun 09, 2019 9:25 pm

sawhorse wrote:
Sun Jun 09, 2019 9:05 pm
partner wrote:
Sun Jun 09, 2019 6:53 pm
It seems to me that insurance companies don't really care if they are getting ripped off. One day while looking over the claims on my insurance companies web site (my account), I noticed a claim from a doctor that I had never seen. I notified the insurance company and they said they would investigate. I tracked the claims progress and each time it progressed, I call the insurance company and repeated the story, they saw in the record that it was supposedly being investigated. Since it showed that I owned a co-pay, I called the doctors office and asked about it. Their records showed that I was not there that day and could not explain the bill. And of course I did not owe any co-pay. I gave up calling the insurance co after a while when it became clear they were not concerned about it. The last entry in the insurance company record was they had sent the dr a check. This was Aetna.
I've experienced this too. I had an urgent care billed insurance twice for the same $167 swab test, and insurance paid for it twice. I notified the insurance company, and they didn't do anything about it.

It's especially puzzling because they go out of their way to deny some claims, but they'll gladly pay for some claims that they have been told are false.
Interesting. I suspect this is, ironically, a financial issue for insurance companies. Almost the opposite of my office back when I used to be in-network with insurance.

I used to have office visits denied by insurance for no apparent reason. The insurance rate for these visits was about 60 dollars. When I pay my billing staff $20 an hour, if she spends more than 2 hours on this claim (filing, refiling, appeals, sitting on the phone, etc) then I start losing money once you add in the rest of the office overhead. So I told her if she goes more than 1 hour with a $60 visit, to just drop it and move on to the next one. Insurance companies KNOW this and deny for this reason. They know many will never chase it. Multiply this by 10+ visits per week, and the insurance company just saved $28,000 just from one single doctors office. Death by a thousand paper cuts.
This is precisely the reason I no longer take insurance. Previously I would do 100 operations and get paid for maybe 70. Now I do only 40 and get paid for 40, which is much better.

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