Re: GEN: How do insurance carriers do this? (long)
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Sun Feb 27 06:56:50 2005
Of course, Dan.
Now that being said, what about the women whose complaints include
pelvic pain and infertility? Let's say she doesn't have infertility
coverage, but after appropriate testing for both--let's say an
ultrasound, HSG, and SA may well be a candidate for a lapscope. I would
do her scope and bill it under both, wouldn't you?
Garry
At Sun, 27 Feb 2005, R. Daniel Braun wrote:
>
>Any one where you change the diagnosis to get them to pay.
>
>On Sat, 26 Feb 2005 21:05:51 -0600, Garry E. Siegel, M.D.
><garrys@mindspring.com> wrote:
>> 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
>>
>--
>R. Daniel Braun
> Kinky for Governor
>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
