Author Topic: Re-submitting as routine?  (Read 2985 times)

wildcat1842

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Re-submitting as routine?
« on: December 03, 2009, 11:11:22 AM »
Hi! I work for an ophthalmologist. We saw a patient for his yearly exam. We have seen him before, he has cataracts and macular degeneration. The dr coded the visit for those diagnoses. The insurance companied applied the visit to the patients deductible. The patient called to complain, and the insurance told him that if we submitted it as a routine exam, they would cover it. Is that legal? If I submit it again with a routine diagnosis, is that fraud? Thanks!

Pay_My_Claims

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Re: Re-submitting as routine?
« Reply #1 on: December 03, 2009, 01:50:11 PM »
what they are telling you is it was done as a medical visit, instead of a routine eye exam. I can't tell you that you should change it...but if it was a routine eye exam it should have been coded as such. What did the opthlamolgist see him for? Vision exam? or medical

Michele

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Re: Re-submitting as routine?
« Reply #2 on: December 03, 2009, 08:48:50 PM »
Most ophthalmologists don't do routine exams do they?  Anyway, you need to ask the dr what he saw the patient for, routine or medical.  We've actually run into this many times.  The patient makes the exam as a routine check up, encounters a medical problem and it goes out as a medical visit.  The dr needs to make the call as he is the only one that was in the room (besides the patient :) )

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wildcat1842

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Re: Re-submitting as routine?
« Reply #3 on: December 07, 2009, 01:48:14 PM »
Thank you guys! The patient did come in for a routine exam, but the dr found medical diagnoses. If we changed the diagnosis and re-submitted it, would that be breaking any rules/laws?
« Last Edit: December 07, 2009, 01:52:48 PM by wildcat1842 »

Steve Verno CMBS, CEMCS

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Re: Re-submitting as routine?
« Reply #4 on: December 07, 2009, 06:34:47 PM »
Corrected claims can always be submitted when an error has been found.

It is my experience, some patients dont want to pay their deductibles, so they call us and tell us to rebill their insurance.  We tell the patient the claim was processed and the payment was applied to their deductible.  Usually that results in, "YOU PEOPLE F***ED UP!  SEND THE GD CLAIM BACK.  THEYRE SUPPOSED TO PAY MY CLAIMS IN FULL. IM NOT PAYING FOR YOUR MISTAKES.  We didnt make any mistakes. Now we call with the patient on the other line.  We inform the insurance company to educate their member about deductibles.  Next comes:  IM NOT PAYING, I WASNT SATISFIED WITH WHAT THE DOCTOR DID.  or IM NOT PAYING THIS.  THE DOCTOR JUST PEEKED HIS HEAD IN THE ROOM.      
Wit something like this, we pull the chart, have it reviewed by our evaluation department and a disintereste physician in the department.  Once the eval is completed a final report is sent by the physician to the patient.  Sometimes the patient calls and yells, YOU PEOPLE F***ED UP AND IM SUEING YOU.  We still wait for the court paperwork to come in.  In the meantime, the patient continue to be biled for their deductible.  If the account becomes delinquent, it goes to our collection agency.  A couple of years goes by when the collection agency calls me. 'Mr. Verno, we got a call from Mr. Potatoe Head. He' trying to get a loan to remortgage his home and they ae refusing it.   He says we messed up and demands the claim be sent to ABC Insurance company or he will sue us. He demands we stop all collections because we are violaing the law by trying to collect this debt.  "  No problem.  We send a copy of the EOB to the collection agency along with he evaluation boards report.  The collection agency is informed they can continue debt collection.  Now, the angry man is walking through the front door.  he yells and sceams to speak with the doctor.  An employee is calling the police while we try to calm him down.  One man walked into our office with a handgun. From then on, our physical address is no longer on the statement. Only the bank lockbox address is on the statement.  One paient went so far as to find the doctors home address.  He couldnt get in to the doctors home as he lived in a private gated community on an island where other doctors lived.  The one patient who came to our physical address went to the hospital and while in the lobby was yelling the doctors name.  The things patients will do to keep from paying their bills.   You gotta love our profession.  
« Last Edit: December 07, 2009, 06:50:50 PM by Steve Verno CMBS, CEMCS »
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Michele

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Re: Re-submitting as routine?
« Reply #5 on: December 07, 2009, 07:29:01 PM »
If the dr is ok with it being considered a routine exam, then you aren't doing anything fraudulent.  As long as the patient's chart also shows it was a routine exam.  I find that the dr walked into the room intending for it to be a routine exam, found a medical problem, and then it really could go either way.  That is why the dr has to OK the change from medical to routine.  And the notes must also reflect it.  They can show that the dr addressed the medical concern, but the main reason for the visit was routine.

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Pay_My_Claims

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Re: Re-submitting as routine?
« Reply #6 on: December 07, 2009, 07:36:41 PM »
Thank you guys! The patient did come in for a routine exam, but the dr found medical diagnoses. If we changed the diagnosis and re-submitted it, would that be breaking any rules/laws?

If the routine eye exam turned into a medical exam the MD did the right thing and billed as such, however, the patient had the right to know prior to, and changing it to suit the needs of the patient IMO is fraud. The MD documented a medical exam, therefore that is what we bill. The MD could have told the patient. Sir/Madam, your preliminary test are showing some medical issues that we need to address, so therefore I need to reschedule your routine eye exam to address these issues and see you under our medical services to futher assist you.

Michele

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Re: Re-submitting as routine?
« Reply #7 on: December 09, 2009, 08:36:43 AM »
Charlene is right.  If the exam distinctly became medical then it should not be changed.  However, that is why I said that the Dr is the only one who can make that call as he was in the room and provided the service.  Did he perform a routine exam, but note a medical problem and make the patient aware of it?  Or did the visit turn from routine to medical.  We bill for several eye drs and run across this regularly.  The dr always has to make the call.  Also, we never change them based on the patients needs or requests.  However, as Charlene also stated, it is imperative that the Dr inform the patient during the visit so they are not surprised!  :)

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Anand

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Re: Re-submitting as routine?
« Reply #8 on: December 18, 2009, 02:57:20 AM »
I agree with Michele&Charlene. They are right. As a matter of fact codes cannot be changed just to get payments or the way patient wants to be. We have instances in my office too.. We get a lot of Pt calls on this issue. As Steve pointed out sometimes it will be cumbersome process to make the pt understand. I would go ahead and check with the Dr and confirm if the service were rendered as a routine or it was changed based on the medical necessity of the ailment.

Thanks,
Anand.

Steve Verno CMBS, CEMCS

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Re: Re-submitting as routine?
« Reply #9 on: December 18, 2009, 10:40:15 PM »
I went to my personal physician the other day.  He was trying to come to the room I was in.  An angry senior citizen was blocking his way, yelling and screaming at the top of his lungs.  he ws accusing the doctor of fraud.  He said his insurance company told him if the doctor changed his diagnosis, his insurance company would pay the bill.  He must have said he would sue about 10 times. My doctor was excellent, he kept his cool.  He took the patient into a private room, asked me if I could help.  He asked the patient if I could see his chart.  He explained to the patient about my credentials.  I looked and explained that the doctor used the right code.  I showed the patient what the code was. I showed the code tat the insurance company wanted  The patient calmed down, admitted he used the internet to do some investigation.  He said he went to an internet site and someone responded saying the doctor was committing fraud.  I asked, was this person a coder?  Nope!  Just someone who was anonymous.  I explained that we cannot change what is documented just because an insurance company wants something change.  I also explained if we changed the code, we might be committing fraud.  The patient apologized and left saying he would give the insurance company a call.  The doctor thanked me.  I was impressed.  He said he was used to it when he did his intership and residency in Brooklyn.   
I'l have a double chubby chuck, a mexicali chilibarb, and two cherry cokes
Left hand Blue, Right Leg Green
You got your peanut butter on my milk chocolate.
Dont cut the blue wire! 
I love spam.

Anand

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Re: Re-submitting as routine?
« Reply #10 on: December 21, 2009, 12:56:10 AM »
I went to my personal physician the other day.  He was trying to come to the room I was in.  An angry senior citizen was blocking his way, yelling and screaming at the top of his lungs.  he ws accusing the doctor of fraud.  He said his insurance company told him if the doctor changed his diagnosis, his insurance company would pay the bill.  He must have said he would sue about 10 times. My doctor was excellent, he kept his cool.  He took the patient into a private room, asked me if I could help.  He asked the patient if I could see his chart.  He explained to the patient about my credentials.  I looked and explained that the doctor used the right code.  I showed the patient what the code was. I showed the code tat the insurance company wanted  The patient calmed down, admitted he used the internet to do some investigation.  He said he went to an internet site and someone responded saying the doctor was committing fraud.  I asked, was this person a coder?  Nope!  Just someone who was anonymous.  I explained that we cannot change what is documented just because an insurance company wants something change.  I also explained if we changed the code, we might be committing fraud.  The patient apologized and left saying he would give the insurance company a call.  The doctor thanked me.  I was impressed.  He said he was used to it when he did his intership and residency in Brooklyn.   
..Steve: Is it only the Doctor??I think you must have had issues mostly everday.. :)..haha..Merry Chirstmas..

wildcat1842

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Re: Re-submitting as routine?
« Reply #11 on: December 21, 2009, 05:56:30 PM »
Thank you all again. We will not be re-submitting. Loved your stories Steve, my family is from Brooklyn  :D

PMRNC

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Re: Re-submitting as routine?
« Reply #12 on: December 29, 2009, 09:05:30 AM »
Steve it's so odd all this stuff only happens to you. I think you over-work yourself. If I get an irate patient upset because their payment was applied to their deductible, I'm not there to teach the patient their insurance contracts or rules. I'm not jumping through hoops for them, that's not my job. I explain it once and if they really want to fight I tell them to contact their carrier, union rep or administrator.  I've never let a conversation with any patient go to the level where I am treated poorly, there is not enough money in the world to be treated like that. I apply my customer service skills I learned while working at the insurance company at the first vulgar word the patient uses I inform them that I do NOT have to continue the conversation, they get one warning and if they continue they get a dial tone. I work with mostly mental health providers so I have had to do this a few times. I make it clear to my clients I am not a punching bag nor will I be verbally abused. 
In the situation with the doctor asking you to review the irate patient's chart.. to me that's completely crossing a line and very unprofessional. The proper way for that doctor to have acted was to take the patient in another room and discuss this with them or try to make an appointment for another time or guide him to the billing staff that works for him. If a doctor did that to me while I was waiting to have him see me.. I'd get another doctor! Did you have patient sign any form of release before you looked at her chart?  Sorry but today the legal system has our hands tied and we have to follow the letter of the law all the way around.
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