Re: GEN: How do insurance carriers do this? (long)
From: R. Daniel Braun (rd.braun@gmail.com)
Sun Feb 27 03:26:48 2005
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
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