Author Topic: Letter from Insurance Company  (Read 3870 times)

rdmoore2003

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Letter from Insurance Company
« 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? 
Regina

kristin

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Re: Letter from Insurance Company
« Reply #1 on: August 20, 2014, 07:05:38 PM »
It sounds to me like the insurance company is encouraging insurance fraud.

PMRNC

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Re: Letter from Insurance Company
« Reply #2 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
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shanbull

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Re: Letter from Insurance Company
« Reply #3 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.

rdmoore2003

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Re: Letter from Insurance Company
« Reply #4 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.
Regina

rdmoore2003

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Re: Letter from Insurance Company
« Reply #5 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. 
Regina

rdmoore2003

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Re: Letter from Insurance Company
« Reply #6 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.
Regina

PMRNC

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Re: Letter from Insurance Company
« Reply #7 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.
Linda Walker
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rdmoore2003

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Re: Letter from Insurance Company
« Reply #8 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. 
Regina

Michele

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Re: Letter from Insurance Company
« Reply #9 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
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PMRNC

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Re: Letter from Insurance Company
« Reply #10 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!!
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kristin

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Re: Letter from Insurance Company
« Reply #11 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.

Michele

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Re: Letter from Insurance Company
« Reply #12 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. 
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PMRNC

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Re: Letter from Insurance Company
« Reply #13 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.
Linda Walker
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rdmoore2003

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Re: Letter from Insurance Company
« Reply #14 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.....
Regina