Re: GEN: How do insurance carriers do this? (long)
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Sat Feb 26 20:05:40 2005
Dan:
If I do what? Which example are you referring to?
Garry
At Sat, 26 Feb 2005, R. Daniel Braun wrote:
>
>If you do that and they catch you, it is FRAUD and a jail sentence could follow.
>
>On Sat, 26 Feb 2005 16:31:13 -0600, Garry E. Siegel, M.D.
><garrys@mindspring.com> wrote:
>> A discussion with a patient whose infertility is non-covered leads to
>> this long diatribe I've often wondered. Any thoughts welcome.
>>
>> The broad topic is how to insurers review claims and decide which are
>> paid automatically (i.e. probably no human input) and which are
>> reviewed.
>>
>> For instance:
>>
>> Mid level office visit, dx. endometriosis
>>
>> I would think this is paid without review, as the CPT and ICD-9 jive,
>> AND it is not an expensive amount.
>>
>> Now, what about:
>>
>> TAH, dx. Fibroids
>>
>> I would think that this is another slam dunk, but maybe the PROCEDURE or
>> the AMOUNT merit automatic review.
>>
>> So. . .
>>
>> If I bill a laparoscopy for a yeast infection, does the mismatch of
>> diagnosis/CPT generate a red flag? Or, does every surgery get reviewed?
>> Or, does any CPT that is paid over a certain dollar amount get reviewed?
>>
>> So. . .
>>
>> If I tried to bill a lapscope done in reality for infertility, but used
>> Pelvic Pain as the diagnosis, would the carrier catch it? Now, realize
>> I'm not doing this (unless she has documented pelvic pain). Also, if
>> the patient has previously had CPTs billed that are obvious, i.e. an
>> HSG, do they know?
>>
>> As an aside, someone on Clomid with oligoovulation can be billed for
>> office visits under "irreguar menses," I suppose, but if the carrier
>> sees a bill from the pharmacy for Clomid, do they figure it out?
>>
>> Whew!
>>
>> Garry
>>
>> --
>> Garry E. Siegel, M.D.
>> Private Practice
>> Roswell, GA
>>
>--
>R. Daniel Braun
> Kinky for Governor
>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
