Medical Billing Forum

General Category => General Questions => Topic started by: rdmoore2003 on August 20, 2014, 04:03:21 PM

Title: Letter from Insurance Company
Post by: rdmoore2003 on August 20, 2014, 04:03:21 PM
Let me start by explaining what is going on.  I have a patient that her secondary insurance does not cover a specific diagnosis.   The patient has Medicare as primary, which does cover the diagnosis.   

Now, the secondary insurance company sent the patient a letter.  In this letter, it specifically states, "your provider should change the listed diagnosis so that we, the insurance company, will pay on the claim".   

Does this throw a red flag to anyone other than me? 
Title: Re: Letter from Insurance Company
Post by: kristin on August 20, 2014, 07:05:38 PM
It sounds to me like the insurance company is encouraging insurance fraud.
Title: Re: Letter from Insurance Company
Post by: PMRNC on August 20, 2014, 08:31:55 PM

Quote
In this letter, it specifically states, "your provider should change the listed diagnosis so that we, the insurance company, will pay on the claim".   

I have to ask.. Did you see this "letter"?
I have a hard time believing an insurance company would send a letter like that, sounds to me like the patient read it the way they wanted to read it. I have had plenty of patients tell me they called their insurance company and they told them to change the diagnosis or procedure code. Having worked for insurance carriers myself I can tell you that isn't what we said. LOL
Title: Re: Letter from Insurance Company
Post by: shanbull on August 21, 2014, 11:25:47 AM
Was there more than one diagnosis on the claim? Only thing I can think of is maybe the insurance company meant a different primary diagnosis could be listed, if there were originally multiple diagnoses on the claim. Obviously it would have to be supported by the documentation.
Title: Re: Letter from Insurance Company
Post by: rdmoore2003 on August 21, 2014, 04:50:53 PM
It sounds to me like the insurance company is encouraging insurance fraud.

That is what I thought, too.
Title: Re: Letter from Insurance Company
Post by: rdmoore2003 on August 21, 2014, 04:52:28 PM

Quote
In this letter, it specifically states, "your provider should change the listed diagnosis so that we, the insurance company, will pay on the claim".   

I have to ask.. Did you see this "letter"?
I have a hard time believing an insurance company would send a letter like that, sounds to me like the patient read it the way they wanted to read it. I have had plenty of patients tell me they called their insurance company and they told them to change the diagnosis or procedure code. Having worked for insurance carriers myself I can tell you that isn't what we said. LOL

yes, I did see it. 
Title: Re: Letter from Insurance Company
Post by: rdmoore2003 on August 21, 2014, 04:52:51 PM
Was there more than one diagnosis on the claim? Only thing I can think of is maybe the insurance company meant a different primary diagnosis could be listed, if there were originally multiple diagnoses on the claim. Obviously it would have to be supported by the documentation.

no, just 1 diagnosis.
Title: Re: Letter from Insurance Company
Post by: PMRNC on August 21, 2014, 05:00:03 PM
You may not like me for saying this..but I'm TRULY having problem with any letter that states:  In this letter, it specifically states, "your provider should change the listed diagnosis so that we, the insurance company, will pay on the claim".   

I'd have to see it with my OWN eyes to even begin to comprehend.
Title: Re: Letter from Insurance Company
Post by: rdmoore2003 on August 22, 2014, 09:10:43 AM
YES, I WAS SHOCKED AS WELL.  OF COURSE WHEN I WENT TO MAKE A COPY, WE HAD AN INCIDENT IN OUR OFFICE THAT WE HAD TO GET PATIENTS OUT IMMEDIATELY AND I NEVER GOT THE COPY MADE.   I DID READ IT OVER AND OVER AGAIN, AS I COULD NOT BELIEVE WHAT I WAS READING.  I EVEN HAD OUR BOOKKEEPER READ IT AS WELL TO SEE IF I WAS "HALLUCINATING" OR "IMAGINING" IT. 
Title: Re: Letter from Insurance Company
Post by: Michele on August 22, 2014, 02:29:26 PM
One of my employees was recently told by a UHC customer service rep that "if you change the dx from 362.10 to 362.11 then it will pay".  I couldn't believe it but she was a new employee and she would not have known this info without being told.   :o
Title: Re: Letter from Insurance Company
Post by: PMRNC on August 22, 2014, 05:43:10 PM
My goodness..   When I worked for insurance carriers (2 of top 5) our dang calls were MONITORED.. "FOR Quality Assurance". LOL
We couldn't give out the amount PAID towards deductible let alone tell a provider to change the dx code!!
Title: Re: Letter from Insurance Company
Post by: kristin on August 22, 2014, 06:12:21 PM
I have noticed in the last year or so, maybe longer, that insurance companies including Medicare/caid have become quite "helpful" with suggestions for diagnosis and modifer changes on claims. It used to be like pulling teeth to even find out why a claim was denied, now they have all kinds of advice for getting the denials overturned.
Title: Re: Letter from Insurance Company
Post by: Michele on August 22, 2014, 06:46:35 PM
It's been a number of years since I worked for a Major Insurance Carrier but we certainly would never tell them what would get something paid.  We only quoted benefits and explained the denials. 
Title: Re: Letter from Insurance Company
Post by: PMRNC on August 22, 2014, 07:00:30 PM
Quote
It's been a number of years since I worked for a Major Insurance Carrier but we certainly would never tell them what would get something paid.  We only quoted benefits and explained the denials.

Yes.. same here.. we couldn't even say $300 of the $500 deductible has been satisfied. we could only say that the deductible was $X and that NO or yes it was satisfied.
Title: Re: Letter from Insurance Company
Post by: rdmoore2003 on August 27, 2014, 04:28:38 PM
I am glad that I am not the only one that has noticed this "new" trend.   Is this legal now?  Isn't it still unethical and illegal to change dx just so insurance company will pay the claim?    I shudder at the thought.....
Title: Re: Letter from Insurance Company
Post by: RichardP on August 27, 2014, 05:21:12 PM
I have a bit of a different take on this.  The practice of medicine and the verbalization of what was wrong came first.  At some point that verbalization began to be written down.  So we then had the practice of medicine plus the writing down of the diagnosis.  All of this existed way long before computers were invented.

The ICD and CPT codes are an attempt to turn into computer language what the doctors have been writing down for centuries.  It is the written diagnosis / procedure that is the legal definition of what is wrong with the patient and how it was addressed - not the ICD and CPT codes.

So - a doctor may be extremely proficient at making diagnoses (plural), and less proficient in selecting the codes that best match his diagnoses (plural).  That is, after all, what ICD10 is supposed to address.  The ICD9 codes are much less specific; the ICD10 codes, of which there are thousands more, are much more specific.

So - if the doctor's written notes support a 362.11, but the doctor wrote down 362.10, is it illegal to change the code?

If an insurance phone person says "we can pay this if you can change it to 362.11", I would like to think they are saying "have the doctor check his notes to see if they will support a 362.11".  To me, that is an approach far removed from simply advising someone to change a code just to get it paid.

As we approach the change-over to ICD-10 (assuming it ever happens), I imagine it is going to be a nightmare of incorrect coding submitted to the carriers.  I would not be surprised if they are training their staff in the art of educating their clients (the doctor's and their staff who submit billing to them) on which codes are more useful, and which codes are less useful - assuming the written documentation supports the more useful codes.
Title: Re: Letter from Insurance Company
Post by: PMRNC on August 27, 2014, 05:43:38 PM

Quote
I am glad that I am not the only one that has noticed this "new" trend.   Is this legal now?  Isn't it still unethical and illegal to change dx just so insurance company will pay the claim?    I shudder at the thought.....


Yes it is.. IF this is a new trend .. which sorry folks, I'm not buying it because I've worked for a few of the top 5 carriers, then I would think it's up to US to do the due diligent thing.. carriers make the disclaimer that "verification of benefits is not a determination of payment.. blah blah.." well it's up to us also to adhere to our own ethical standards and following the rules. One would ONLY hope that an experienced professional would NOT do something because a carrier told them to do so. I'm just NOT ready to believe a carrier would say this.. people don't understand how they go through the rating process and how that could easily bring their rating down.. I'd really HAVE to see the letter to believe it.. I just don't.   J M H O