Medical coding fraud???
 

Does anyone know who we would call to investigate a physician who has coded an office visit incorrectly? This error has cost us nearly $1,000.00. We would like to have this practice investigated...Thanks for you help.

Call the Medicare Fraud Dept.

Was there discussion with the doctor's office regarding why the service was coded the way it was?

Bill :)

The cpt codes are on line, you can look it up to see if it looks right. If you are on Medicare, the eob tells how to dispute. If private insurance , call the nurse line. You can discuss it with the Dr. Not the staff. Send me a pm.

Dear Bill, Yes many conversations with office staff. She said coding has to match Doctors dictation for the visit, which she read to me. She states she saw me for Hypothyroidism and it was a meet and greet, get established with a new physician visit... I am not on medicare, regular insurance and they said they would pay if she changed it to routine labs, which is what they were. I would like to have some leverage to use against the office by contacting an investigating agency to have it looked into. Thanks for any help as to who to call...

First, you need to try and work it out with the Drs. Ofc.. Then contact your insurance company, or Medicare if they are your primary. From experience with Medicare, Medicare really keeps putting the burden back on you to work it out with your physician and can take a good 1 -2 years to finally get Medicare to even care. If you don't have Medicare then call the Florida Dept of Insurance Fraud. I am sure they can help you or at least provide you with what all you need to do. Good luck........

Gary, thanks for the additional detail. Helps me (and others) better understand your situation.

Bill :)

I agree - you really need to speak one on one with the physician, and disclose your concerns. Its not fair to her or him to immediately start an investigation, when there maybe be issues or a coding problem you are not even aware of. Make a record of what transpires in that conversation, and go from there if necessary.

Gotta read them posts, she says not on Medicare.

This appears to be a misunderstanding regarding coding and not intentional fraud. We have had to correct such coding issues more than once with various doctor's offices. The number of various codes was greatly increased which has exagerbated this issue Most doctor's offies will recognize their honest mistakes

Deleted... Post was based on an incorrect observation!

I don't think you all need me anymore. The advice here sounds really good.

Yay team!

Sorry Bogie Shooter, but if you note time of my post was posted before I knew they said they didn't have Medicare. Plus even if it wasn't, it was general steps in case someone else could be in same boat (and that person just may have Medicare).

I'm an RN who worked at MetLife then UnitedHealthcare for 9 years after working 17 years in a hospital so I know about coding. Your statement is confusing to me so I would like more specific info about the visit. WERE you a new patient? If you were, they still have to code it for a new physician visit even if it was only in order to get blood tests ordered. Can you send me a PM about the circumstances that brought you to this doctor?
I'm also interested in why this is costing you $1000.

The doctor has to code the service provided, not for the service the patient has the best coverage. Labs can be coded as being done because of an illness which is known, or being done as screening tests. Insurance rules are very specific to your policy. Some carriers don't care why the test was done, some do. If you have a known illness then the doctor certainly didn't order tests without at least doing a history and hopefully vital signs and some element of a physical exam. As you say you were read the office note you should be able to evaluate what elements of an office visit were provided. If you were tested because of a diagnosis and to ascertain whether your therapy or disease were under control, that is not a routine lab (screening) it is a diagnostic lab. I have no idea what thyroid lab test would possible get you to $1000. That is where you may have to chat with the doctor. Did your medical situation require all the tests that were ordered or was every thryoid test known to man requested? Did the doctor do the labs in office or send you out to an independant ? In the first case the doctor makes the lab test profit which incentivises unnecessary testing. If you were sent out the doctor made no money on the tests. There are no kickbacks except maybe a Xmas fruit basket. The doctor cannot change the coding if it is already correct to try to get you better insurance coverage. That would be insurance fraud.