I used to work for a billing company and if they got a superbill with aprimary diagnosis that they knew an insurance company would not pay for, ie. mental problems, hair loss, obesity, but the doctor put other problems, say hypertension, they would list the medical diagnosis and omit the non covered ones. I think this is insurance fraud. If so, how could an audit be done anonymously? I would love to close them down. You can tell I have a beef with this company.
2007-07-27 07:00:15 · 3 answers · asked by letsroll 1 in Business & Finance ➔ Insurance
Yes, its fraud.... However, its really tough to prove. Ultimately, you'd have to start with an insurance company they have 'defrauded' at some point. Call them. Tell them you wish to report suspected fraudulent activity. They all have a 'fraud investigation' unit... Someone will speak w/ you & take any information you have concerning suspected activity... They don't care if you're blowing the whistle, or a patient.... They just want it to stop.
An insurance company would have to request chart notes and the super bills to investigate the accusations... its lengthy & tedious. CYA!!!
2007-07-27 14:59:06 · answer #1 · answered by Custo 4 · 0⤊ 0⤋
Actually, if the other problem was discussed or addressed during the visit where the primary diagnosis was something else, it's not exactly fraud - unless it was never documented. Sometimes my docs list three or four different diagnoses, and it's up to me to pick the most pertient one(s), based on the notes from the visit. So, for example, if someone came in complaining of hair loss, but the doctor found an underlying thyroid issue, the diagnosis would then be hypothyroidism.
Asking for an audit is more hassle than it's worth, and for it to come from a spiteful ex-employee could really bite the ex-employee in the *ss. Eventually, if what they're going is illegal, it WILL come back to them.
2007-07-27 09:45:02 · answer #2 · answered by zippythejessi 7 · 0⤊ 0⤋
I wouldn't do it, because the insurance fraud may be on the doctor, but it is the patient who has to pay. The doctor is actually helping the pt by using a diagnosis (that the pt porbably qualifies for, and if they have the syndrome that is diagnosed, it isn't insurance fraud) so that the insurance company will pay more for the procedure. This keeps money in the poor pts pocket and makes the doctor happy and able to continue treating this person.
Don't take personal grudges out on the sick patients.
2007-07-27 07:09:38 · answer #3 · answered by Malina 7 · 1⤊ 1⤋