Re: GEN: How do insurance carriers do this? (long)
From: R. Daniel Braun (rd.braun@gmail.com)
Sun Feb 27 08:38:46 2005
Yep, and neither one of us gets paid because we are honest and it gets
kicked out because of the infertility diagnosis.
On Sun, 27 Feb 2005 07:57:30 -0600, Garry E. Siegel, M.D.
<garrys@mindspring.com> wrote:
> 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
>
--
R. Daniel Braun
Kinky for Governor
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