what do when doctor claimed the preventive care service to insurance as medical neccesity?

Question

I visted the doctor for my annual preventive cares services and had the tests done. But when I

saw the claims with my insurance I saw that it was not filed as Preventive Care and insurance had

paid the money from my HRA account. The service is suppose to be free and 100% covered.

I talked to the doctor and his agent to cancel this claim but they are not helping since they got

paid. I went back to insurance and they are say I need to talk to doctor.

What to do in this case so that I get back money so that I can use it for other neccessary

medical benefits?

The doctor cheated and did not file the claim as preventive.

Now I an helpless with insurance, the doctor and his agent.

How do I take up this matter and get back my money?

Please suggest.

Answer 1

Your insurance company has to process the claim as it was billed by the doctor's office. The only way that the claim can be reprocessed is with additional information from your doctor's office.

Be forewarned that its possible that your service wasn't truly "preventative." If you have a chronic condition such as high blood pressure, high cholesterol, diabetes, etc. and the doctor discussed any of those issues with you or ordered any blood tests to monitor one of those conditions, then your doctor's office would be correct in billing it with a medical diagnosis.

The way that a medical claim is billed has to reflect the services that were actually provided - not what your intent was when you scheduled the appointment.

Best thing you can do is request a copy of your chart notes from that visit. If everything in the notes indicates that the services done were "routine" or "preventative" in nature, then the claim should reflect that. However, if anything in the chart notes indicates a medical diagnosis, then there's nothing you can do. (Ex - notes saying something to the effect of you having a history of high cholesterol, so the doctor ordered blood work to check your current levels. That would be "medical," not "preventative.")

Answer 2

I hate to say this, but the insurance company is right. They have to process the claim the according to how the doctor's office coded the bill. They only way the insurance can get your money back is if the doctor's office sends them another bill with the correct coding on it. So the only thing they can really do is call the doctor's office on your behalf and see if they can get the doctor's office to change the coding on the bill. I used to work as a customer service rep for a health insurance company's claims department and people would call in quite frequently with that type of problem.

I would suggest calling the doctor's office again and maybe speak with a supervisor or the doctor. If that doesn't work you can even try calling the insurance again. Just explain to them that you understand the doctor has to make the correction but you would appreciate it if they would assist you in this matter. They should help you if their nice (I did when people called in about this). Keep in mind though, that the insurance can't make them rebill it, they can only help you in convincing them to send them a corrected bill.

Answer 3

If the doctor filed an incorrect claim, it can be considered insurance fraud.

The first thing I would do is call the doctor's office, ask to speak to whoever is in charge of billing and insurance, and I'd tell them since they filed an inaccurate claim, they need to fix it. If they still refuse, tell them that you're going to 1) file a fraud claim with your insurance company, and 2) file a complaint with the state insurance commissioner.

Also, you may file an appeal with your insurance company.

And I'd definitely start looking for a new doctor - you don't want to entrust your healthcare to a place that is so obviously unconcerned about your wishes.

Answer 4

Another option is to request a copy of your records from the visit and send them into your insurance company requesting they review the actual records compared to the charges that were submitted. Tell your insurance company you suspect the physician of fraudulent billing and you would like them to investigate.

You could also try contacting the dr's office again and tell them that if they do not submit the bill properly, you will be filing a complaint with your state's insurance commissioner and your insurance company and request that they investigate for possible fraudulent billing.

Answer 5

Send a request in writing to your doctor's office stating you want a copy of the office notes from your chart for that date of service. As long as you request them in writing, they are legally bound to provide them to you. (If you need to, request a copy of your entire chart.) You may have to pay for it, but it might be worth it. If the chart clearly states that it was a preventative exam, then you file a complaint with your insurance company - you have the documentation to prove it.

However, if you discussed anything else at the visit - for example, if you have an ongoing health issue (asthma, diabetes, etc.) technically, they CAN bill it as a visit for that, but they've got to document it fully. The proof is in the pudding, so to speak.