Wiki private payer fraud?

[meandmya@msn.com]

If there is reason to suspect abuse/fraud is occuring in a physicians office that only participates with non goverment/private insurances is there anyone to can contact within the state or federal government or is this just a matter between the private insurances and the provider?


Thank you.

 

[greatbiller]

If you are a patient of the practice, contact your insurance carrier. Otherwise, you may want to get in touch with the district attorney in your local area, but they more than likely will need some type of proof that fraud is occurring. Unfortunately, with limited resources and higher priority crime to address, unless there is clear cut evidence to support fraud, they may not investigate the provider.

If you are an employee and you suspect fraud, you may be able to get the insurance carriers to investigate.

Good luck!

Patricia Murrin, CPC, RCC

 

[meandmya@msn.com]

Thank you! I had a consult with a provider and will not be going back due to the billing practices that were discussed during my consult. The practice expected me to pay for an interpretation and report for tests when they were billing my insurance for a code that clearly included interpretation and report. The physician argued that insurance doesn't pay them enough so they bill the patient for the time it takes for them to prepare reports. Their policy is even on the Web!!! I have contacted my insurance and reported this however it is difficult since I have a Blue Card plan. I will check into the State Attorney's office. If this provider is seeing just 3 patients a month with BCBS for testing using this billing methodolgy he is gaining 21,000 extra a year. Doubtful he is only seeing 3 patients a month and there are 4 providers in this practice billing the same thing.

I am so glad to be in this profession. Think of how many people are out there that just go ahead and pay for what they should not be billed for. I usually am a provider advocate but, in this case - not so much.

 

[cyndeew]

You could go directly to the physician's professional board. That will get his/her attention real fast. You can also complain to the Better Business Bureau as well as give them a bad rating online. Those things do hurt practices.