Medical Billing Forum

Starting a Medical Billing Business => Starting Your Own Medical Billing Business => Topic started by: ste on November 05, 2010, 04:31:39 PM

Title: Insurance contacts patient
Post by: ste on November 05, 2010, 04:31:39 PM
I have been billing for this particular CAM provider for 10 months. A family of three sees this practitioner on a fairly regular basis and I must say the insurance pays better than most. The head of the household recently received a phone call from the insurance telling him that this particular provider is not a doctor, he and his family shouldn't be seeing this provider, the provider isn't covered, and on and on. The insurance went to great lengths to dys the provider and did so in a rather threatening manner.
I have not been contacted by the insurance, the provider has not been contacted by the insurance, and I am at a loss as how to respond. I am not even sure I should respond?
Is this something the state insurance commissioner should hear?
A year ago I had 0. Today, I have 18 and am a bit overwhelmed, but I am having fun. What a difference a year can make.
Steve   
Title: Re: Insurance contacts patient
Post by: DMK on November 05, 2010, 05:51:34 PM
JMO but for your peace of mind, if the provider wasn't a provider, the insurance wouldn't pay him!  He has to be registered with NPI, licensed and a verified provider or they wouldn't pay him in the first place!

The provider should contact the insurance company, the patients should report it to higher ups at their insurance company and the insurance commissioner should definitely be notified!

Now I'll show my ignorance....what is a CAM provider?
Title: Re: Insurance contacts patient
Post by: ste on November 05, 2010, 11:14:59 PM
CAM = Complementary and Alternative Medicine
Title: Re: Insurance contacts patient
Post by: ste on November 05, 2010, 11:30:52 PM
The provider is a bona fide provider with an npi and all the bells and whistles. Provider has been seeing these 3 family members for some time, sending me superbills, I sumit them to the insurance in question, and the insurance has been paying the claims.
Title: Re: Insurance contacts patient
Post by: PMRNC on November 06, 2010, 11:22:20 AM
Sounds like an internal investigation is taking place. I would definitely NOT just sit on this and do nothing if you are doing the billing. If you are billing and now have reason or suspicion of wrong doing, you are now JUST as libel. I would definitely contact the insurance company and make an inquiry to get the specifics so you can make a decision for your own liability and as well as educate the provider. It's not uncommon for an insurance company to notify the insured of an investigation pending or otherwise and not inform the provider while doing so..if they continue to pay claims..well then I'm at a loss.  BUT regardless..you have knowledge that something is not right and that puts liability on you from that moment forward. You should probably consult your contract and your own compliance plan and take action in accordance with those things, your compliance plan is important in cases like this as it is (or should be there) to refer to when things like this come up.
Title: Re: Insurance contacts patient
Post by: ste on November 06, 2010, 04:55:49 PM
I have been doing the billing and proudly continue to do so. I don't suspect any wrong doing on my part or the provider's part. I have looked into recent claim activity on-line and found a claim with "payment is denied when performed/billed by this type of provider." I also found another claim on a different family member with a later DOS that has been accepted and "finalized for payment" although a check has not yet been issued.
I reviewed the policy booklet and specialty is neither included as a covered benefit, nor is the specialty mentioned in the general exclusions section. When I verified benefits 10 months ago the specialty was a covered benefit for office visits, although the disclaimer on benefits verifications throws that defense out with the bath water.
I guess my biggest fear is that the insurance company will say, "No. This specialty is not a covered benefit. So, give us back all the money we have paid you thus far."
Can an insurance company do this? And yes, I will call them on Monday.   
Title: Re: Insurance contacts patient
Post by: Michele on November 08, 2010, 09:52:52 AM
I'm actually surprised that they were paying.  Please don't interpret this incorrectly.  I'm not saying that I personally do not think that this provider does not provide a very good service to patients, I'm saying in my experience Insurance Carriers do not usually cover these types of providers because they consider the treatment not proven.  It is a possibility that they could come back and state that the claims were paid in error, and request the payments back.  :(  I've seen it happen. 

But Congrats on the 18 accounts!   ;D

Michele
Title: Re: Insurance contacts patient
Post by: PMRNC on November 08, 2010, 01:36:07 PM
Quote
I have been doing the billing and proudly continue to do so. I don't suspect any wrong doing on my part or the provider's part. I have looked into recent claim activity on-line and found a claim with "payment is denied when performed/billed by this type of provider." I also found another claim on a different family member with a later DOS that has been accepted and "finalized for payment" although a check has not yet been issued.
I reviewed the policy booklet and specialty is neither included as a covered benefit, nor is the specialty mentioned in the general exclusions section. When I verified benefits 10 months ago the specialty was a covered benefit for office visits, although the disclaimer on benefits verifications throws that defense out with the bath water.
I guess my biggest fear is that the insurance company will say, "No. This specialty is not a covered benefit. So, give us back all the money we have paid you thus far."
Can an insurance company do this? And yes, I will call them on Monday.

I still have not seen any posts to indicate what type of services are being provided...but when I meant suspicion of fraud or a problem.. I am referring to the fact that the insurance company spoke to the patient..at that point there should be some action on your part not to submit claims until you get to the bottom of it because IF there is any wrong doing, you could hold some liability.. Just CYA is all I'm saying.

Quote
The head of the household recently received a phone call from the insurance telling him that this particular provider is not a doctor, he and his family shouldn't be seeing this provider, the provider isn't covered, and on and on. The insurance went to great lengths to dys the provider and did so in a rather threatening manner.

That's the part that bothers me with this and again, I don't know what services are being provided, etc.  It's possible this could be a fraudulent license....it just would not sit well with me to send another bill until I got to the bottom of that.