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Re-submitting as routine?

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wildcat1842:
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:
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:
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 :) )

Michele

wildcat1842:
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?

Steve Verno CMBS, CEMCS:
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.  

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