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Re: GEN: How do insurance carriers do this? (long) From: R. Daniel Braun (rd.braun@gmail.com) Sat Feb 26 17:15:24 2005 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Garry E. Siegel, M.D.: "Re: GEN: How do insurance carriers do this? (long)" Previous message: Anna Meenan, MD: "Re: Wrongful Death Suit Allowed Over Embryo" In reply to: Garry E. Siegel, M.D.: "GEN: How do insurance carriers do this? (long)" Next in thread: Garry E. Siegel, M.D.: "Re: GEN: How do insurance carriers do this? (long)" Reply: Garry E. Siegel, M.D.: "Re: GEN: How do insurance carriers do this? (long)" 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 Next message: Garry E. Siegel, M.D.: "Re: GEN: How do insurance carriers do this? (long)" Previous message: Anna Meenan, MD: "Re: Wrongful Death Suit Allowed Over Embryo" In reply to: Garry E. Siegel, M.D.: "GEN: How do insurance carriers do this? (long)" Next in thread: Garry E. Siegel, M.D.: "Re: GEN: How do insurance carriers do this? (long)" Reply: Garry E. Siegel, M.D.: "Re: GEN: How do insurance carriers do this? (long)"

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