# Is this fraud??? Help!!! :(



## kbrasington (Oct 17, 2017)

This might belong in the coding forum, but I'm just going to post this here.

So something has come up at my place of employment and I'm wondering if this could be insurance fraud. I'm certain it is, but I'm looking for other insight.

I was reviewing some A/R and we have some really old unpaid claims. I found something from 2015 that was denied because of the diagnosis codes not being covered. So when I called the payer to ask for details, they told me that the diagnosis codes we billed were 643.03 - mild hyperemesis gravidarum (yes these are ICD-9) and 643.10 - hyperemesis gravidarum with metabolic disturbance. The patient does not have any coverage for maternity services, which includes anything related to pregnancy or a complication of pregnancy. That is why they denied the claims. We had been able to obtain pre-cert though, so I asked them what dx codes they had tied to the pre-cert. I was told 401.9, which is unspecified hypertension.

I'm not sure why we gave them the HTN diagnosis though. I looked through all the clinical notes and it was all about how the patient was throwing up non-stop and was malnourished and had anemia and all kinds of problems related to the vomiting, which was a complication of the pregnancy. I couldn't find anything about HTN though'; in fact, most of the BP readings for the patient were normal or low.

My manager called the insurance company back and asked what we could do about this because we "billed the wrong dx code." The rep advised us to send an appeal with the correct dx codes. My manager told me to do it. I told her that the medical records reflected that the patient was being seen for pregnancy complications, and because of this, her services were noncovered. She told me to not worry about what the records said, and to just change the codes and rebill.

As far as the pre-certs are concerned, I have no idea where we got HTN from and why that would have been the primary dx for a home health agency to be seeing such a patient. I suspect we didn't have all the information from when we checked the patient's benefits, and in order to quickly obtain an auth, we just used a generic code like HTN. Not the right thing to do, but I'm guessing that's what we did until we were able to have someone go back and code the entire chart properly...again, this was all the way back in 2015, so the person who obtained the auth doesn't work there anymore.

So my question is, would this be fraud? I don't want to do this and I want to tell the upper management that if the payer comes back and requests medical records, we are screwed, as pregnancy-related services are not a covered benefit and we took the pregnancy codes off the claim form to get around that denial. I am also very scared that management will get mad at me and possibly fire me. Anyone have any insight or can relate? I really need help!! :'(


----------



## CodingKing (Oct 17, 2017)

Yes purposely misrepresenting diagnosis to receive payment is considered a false claim


----------



## kbrasington (Oct 17, 2017)

I should probably rephrase...I know this is insurance fraud and I told my manager we can't bill something that doesn't match the records. I guess I'm trying to back myself up, and also am trying to get advice for how to handle the situation, and to know if anyone has ever been in this situation. I have only been with this company for two months...


----------



## Cheezum51 (Oct 18, 2017)

From what you've said, everything in the medical record supports the chief complaint, exam and MDM being related to pregnancy related problems. Exactly what other code, that could be supported by the record would your supervisor have you file?

If you come up with a bogus code the refile the claim, so you get paid, that would be fraud.

If your supervisor is willing to have you commit fraud for this, what other similar issues will come up in the future?

If there is someone else above your supervisor you can speak with, I'd do that to relate your discomfort with this situation. If that person tells you to do the same fraudulent thing with the claim, you may want to consider working at another more ethical office. If they force you to file the claim, and you're not in a financial position to go elsewhere, document who instructed you to do that with dates and times etc and that you objected to doing this.

Tom Cheezum, O.D., CPC, COPC


----------



## kbrasington (Oct 18, 2017)

Thank you for the response. They wanted me to refile with 401.9, unspecified hypertension. I refused, and now they have spent the entire day so far in a meeting talking about me. So now I am worried I will be fired. I haven't had a chance to talk to anyone other than being yelled at by my manager and threatened by disciplinary action.

She asked the other person at the office who does all the coding to change the codes and assessments and he did it. I am not sure if he is aware that the patient's plan does not cover maternity related services, or that he doesn't want to deal with also being yelled at, or if he doesn't care. When I went back to reread the clinical notes, I noticed that the patient had given birth at the hospital while in our care to a severely underweight (2 pound) baby. The only thing that I can see in the clinical notes about the patient is that she is severely underweight and malnourished and cannot stop throwing up, and is in pain, all related from pregnancy. 

Additionally, my manager then proceeded to yell at me because she saw that I had the patient's chart open, and she told me that she is handling it now.

I actually went home from work yesterday feeling sick to my stomach over this issue because I fear it will cost me my job, but I'm not going to bill something that is fraudulent.


----------



## greatbiller (Oct 18, 2017)

Stand your ground.  You are absolutely correct in your feeling that this is fraud.  Keep copious notes about the case which will help if they try and contest any unemployment claim you may be forced to file.  If they do fire you, I would consider consulting a labor law attorney regarding wrongful termination.


----------



## hduscio789 (Oct 20, 2017)

I agree with all the above. Stand your ground. Let us know what happens. Continue to do what is right, don't let someone force you to commit fraud. It's not worth the consequences.


----------



## RebeccaB (Oct 20, 2017)

Absolutely completely fraud..I would start looking for a new job..if they are willing to do this for a claim payment..what else ???
Not something to be involved in 

Good luck to you

Rebecca


----------



## LisaAlonso23 (Oct 24, 2017)

I am so sorry to see you in this position. Your billing/coding community supports you. Even though it doesn't pay the bills, know that integrity is worth its weight in gold.


----------

