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Letter from Insurance Company

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rdmoore2003:
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? 

kristin:
It sounds to me like the insurance company is encouraging insurance fraud.

PMRNC:


--- 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".   
--- End quote ---

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

shanbull:
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:

--- Quote from: kristin on August 20, 2014, 10:05:38 PM ---It sounds to me like the insurance company is encouraging insurance fraud.

--- End quote ---

That is what I thought, too.

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