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  1. #1
    Senior Member Ronno6's Avatar
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    Should I Rat Out the Medical Professional??

    It pays to watch the medical and dental professionals.
    I discovered that the office of one of the above professions was
    assigning an incorrect professional procedure code to treatment that I was receiving.
    (The code they assigned basically indicated a nebulous non-specific procedure, instead
    of the specific procedure actually performed.)
    This resulted in NO payment of benefits from the insurance company, and me footing the entire
    cost of services rendered, to the tune of about double what I should have paid had
    they coded the procedures correctly.

    I compiled evidence from the web as to what the CORRECT procedure codes (recognized by my insurance) should have been, and the amount that I should have been responsible for as a copay.
    The office manager, who assigned the incorrect codes, just brushed off my documentation,
    indicating that he knew better. Basically he just blew me off, and told me I was fighting a losing battle pursuing
    it any further.
    He doesn't know me very well...............
    One call to the head office proved my assertions to be correct, and I was (eventually, after many phone calls)
    given a check refunding the difference.I had to have somebody climb the internal ladder to the top to get things done,tho.

    Now, the question is: Do I blow the whistle on them?
    I am sure that, having done it to me, they did likewise to other patients, probably in significant numbers.
    At least out of the office I visited, and maybe other offices in the conglomerate (there are MANY!)

    What should U do ??
    Where do I go from here??

  2. #2
    Me and the cat... Pamestique's Avatar
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    I say life is too short - you already spent way too much time on this and at least got your refund. Let it go - get on your bike and go ride instead...
    ______________________________________________________________

    Private docent led mountain bike rides through Limestone Canyon. Go to letsgooutside.org and register today! Also available: hikes, equestrian rides and family events as well as trail maintenance and science study.

  3. #3
    Galveston County Texas 10 Wheels's Avatar
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    Quote Originally Posted by Pamestique View Post
    I say life is too short - you already spent way too much time on this and at least got your refund. Let it go - get on your bike and go ride instead...


    Ok
    [SIZE=1][B]What I like about Texas[/B]
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    Set F1re To The Ra1n ( NY Night Rain Ride)
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  4. #4
    Senior Member himespau's Avatar
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    Give them a bad yelp rating explaining that and leave it at that.
    Punctuation is important. It's the difference between "I helped my uncle, Jack, off a horse" and "I helped my uncle Jack off a horse"


  5. #5
    Senior Member Ronno6's Avatar
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    Quote Originally Posted by Pamestique View Post
    I say life is too short - you already spent way too much time on this and at least got your refund. Let it go - get on your bike and go ride instead...
    This is one of the things I contemplate WHILE riding my bike.................

  6. #6
    Lucille
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    Quote Originally Posted by Ronno6 View Post

    Now, the question is: Do I blow the whistle on them?
    Yes. That kind of fraud makes medical/dental care more expensive for everyone. And not everyone has the persistence and intelligence to analyze the problem and follow through as you did, that does not make them deserving of this kind of criminal fraud. Whether this incident was fraud or not, I don't know, and no one reading this thread can really say for sure, but I think it needs to be investigated. Both links below are to state agencies which will investigate and take action if necessary. The entire complaint process is free, so that the consumer incurs zero costs and other consumers may be protected if the agency finds fraud and takes action.

    https://apps8.fldfs.com/first/
    http://myfloridalegal.com/contact.ns...tizen_Services
    Last edited by Lucillle; 12-11-13 at 12:57 PM.
    Dans les champs de l'observation le hasard ne favorise que l' esprits prepares. Louis Pasteur

  7. #7
    Me and the cat... Pamestique's Avatar
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    Quote Originally Posted by himespau View Post
    Give them a bad yelp rating explaining that and leave it at that.
    Watch doing that - the poster will set himself up for a libel lawsuit...
    ______________________________________________________________

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  8. #8
    Me and the cat... Pamestique's Avatar
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    Quote Originally Posted by Ronno6 View Post
    This is one of the things I contemplate WHILE riding my bike.................
    If it bothers you that much then don't ask for our opinion... do what you feel is necessary for your own satisfaction...
    ______________________________________________________________

    Private docent led mountain bike rides through Limestone Canyon. Go to letsgooutside.org and register today! Also available: hikes, equestrian rides and family events as well as trail maintenance and science study.

  9. #9
    Galveston County Texas 10 Wheels's Avatar
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    Quote Originally Posted by Ronno6 View Post
    This is one of the things I contemplate WHILE riding my bike.................
    OP, you met One person in the profession that made a code error.
    Let your Insurance company handle it.

    Go Ride.
    [SIZE=1][B]What I like about Texas[/B]
    http://www.youtube.com/watch?v=PGukLuXzH1E

    Set F1re To The Ra1n ( NY Night Rain Ride)
    http://www.youtube.com/watch?v=W7jfcWEkSrI

  10. #10
    Can'tre Member 3alarmer's Avatar
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    Quote Originally Posted by Ronno6 View Post

    What should U do ??
    Where do I go from here??
    ...take up another hobby, like knitting or macrame.
    Quote Originally Posted by Terrierman View Post
    No wonder everybody hates you.

  11. #11
    derailleurs are overrated bigbenaugust's Avatar
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    Man, I have had people offer my wife the moon and then some when she leaves even so-so Yelp reviews, much less actual negative ones.
    --Ben
    Carrboro Bike Coalition - putting the "bike" in "CARrboro" :)
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    Previously: 2000 Trek 4500 (2000-2003), 2003 Novara Randonee (2003-2006), 2003 Giant Rainier (2003-2008), 2005 Xootr Swift (2005-2007), 2007 Nashbar 1x9 (2007-2011), 2011 Windsor Shetland (2011-2014)
    Current Linux Usage (by machine): Arch: I openSUSE: III

  12. #12
    Pedaled too far. Artkansas's Avatar
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    Quote Originally Posted by 10 Wheels View Post
    OP, you met One person in the profession that made a code error.
    Let your Insurance company handle it.
    The question is was this a one time goof, or a systematic way of handling it so that the Insurance company gets off the hook and the person gets stuck with the bill that should have been picked up by the Insurance company.

    Given that this "mistake" was one that saved the Insurance company a lot of money, I tend to think that it was rather done as a matter of policy. So, I share the OPs alarm.

    And it may well be that prudent steps to spread the alarm might be wise. I think the first step is to see if he can find others who have had the same problem, to detect whether this is a one time goof or a consistent behavior. Then if it is consistent, then he's got a group of people to go in on a class action suit or something.
    "He who serves all, best serves himself" Jack London

    Quote Originally Posted by Bjforrestal View Post
    I don't care if you are on a unicycle, as long as you're not using a motor to get places you get props from me. We're here to support each other. Share ideas, and motivate one another to actually keep doing it.

  13. #13
    Trek 500 Kid Zinger's Avatar
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    Oh h**l yes !

    Stick it to these overpaid jerks. The insurance companies aren't going to do anything about something that saves them money. It's up to you.
    Last edited by Zinger; 12-11-13 at 01:23 PM.
    "I never lost a race because my bike was too heavy".......George Mount

  14. #14
    Chepooka StupidlyBrave's Avatar
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    Two things to keep in mind:

    - It is very likely an administrative assistant entering the codes
    - Hanlon's razor

  15. #15
    Galveston County Texas 10 Wheels's Avatar
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    Quote Originally Posted by Zinger View Post
    Oh h**l yes !

    Stick it to these overpaid jerks. The insurance companies aren't going to do anything about something that saves them money. It's up to you.
    That is not True in my wife's and my cases.
    [SIZE=1][B]What I like about Texas[/B]
    http://www.youtube.com/watch?v=PGukLuXzH1E

    Set F1re To The Ra1n ( NY Night Rain Ride)
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  16. #16
    Trek 500 Kid Zinger's Avatar
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    Quote Originally Posted by 10 Wheels View Post
    That is not True in my wife's and my cases.
    Well I'm probably not the guy to ask. I'm stuck with a $2000 share of a simple colostomy that I thought would be covered by my insurance and there's not even anything wrong with me.....I'm definitely prejudiced when it comes to medical services in this country and wish I still lived by the Mexican border where I could just avoid them altogether like I used to do.
    "I never lost a race because my bike was too heavy".......George Mount

  17. #17
    Senior Member Shimagnolo's Avatar
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    Quote Originally Posted by Zinger View Post
    Well I'm probably not the guy to ask. I'm stuck with a $2000 share of a simple colostomy that I thought would be covered by my insurance and there's not even anything wrong with me.....I'm definitely prejudiced when it comes to medical services in this country and wish I still lived by the Mexican border where I could just avoid them altogether like I used to do.
    I am pretty sure you did *not* get a _colostomy_ if nothing was wrong with you.
    Now if you told us you got a _colonoscopy_, I'd believe it.

  18. #18
    Trek 500 Kid Zinger's Avatar
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    Quote Originally Posted by Shimagnolo View Post
    I am pretty sure you did *not* get a _colostomy_ if nothing was wrong with you.
    Now if you told us you got a _colonoscopy_, I'd believe it.
    OK. Whatever it was I didn't feel it until I got the bill.
    "I never lost a race because my bike was too heavy".......George Mount

  19. #19
    Chepooka StupidlyBrave's Avatar
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    If you get a colonoscopy, do you get a certificate stating that you're not full of s**t?

  20. #20
    Can'tre Member 3alarmer's Avatar
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    @Ronno6: Benghazi, Bubba...........
    Quote Originally Posted by Terrierman View Post
    No wonder everybody hates you.

  21. #21
    Trek 500 Kid Zinger's Avatar
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    Quote Originally Posted by StupidlyBrave View Post
    If you get a colonoscopy, do you get a certificate stating that you're not full of s**t?
    No but you sure might get a nearly $2000 bill at a time in your life when you can least afford it. If I'd even known about the loophole that lets the insurance company off the hook for it I'd have refused it when my doctor sent me there.

    The OP should absolutely do what he or she can about this whether it was intentional or just through incompetence.
    Last edited by Zinger; 12-11-13 at 02:50 PM.
    "I never lost a race because my bike was too heavy".......George Mount

  22. #22
    genec genec's Avatar
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    Quote Originally Posted by Zinger View Post
    Oh h**l yes !

    Stick it to these overpaid jerks. The insurance companies aren't going to do anything about something that saves them money. It's up to you.
    BINGO! The real question is "Is the office manager somehow in cahoots with the insurance company?"

  23. #23
    genec genec's Avatar
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    Quote Originally Posted by StupidlyBrave View Post
    Two things to keep in mind:

    - It is very likely an administrative assistant entering the codes
    - Hanlon's razor
    But the OP confronted the office manager and without even looking the whole thing was brushed aside... certainly if anything this is a poor way to handle "customer complaints."

  24. #24
    Senior Member Ronno6's Avatar
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    Quote Originally Posted by genec View Post
    BINGO! The real question is "Is the office manager somehow in cahoots with the insurance company?"
    I had not considered that possibility... I wonder how much $$$ the insurance co. pays on a properly coded claim.....

    Quote Originally Posted by genec View Post
    But the OP confronted the office manager and without even looking the whole thing was brushed aside... certainly if anything this is a poor way to handle "customer complaints."
    His ultimate explanation was that he had been instructed to apply that particular (incorrect) code.
    If whoever gave that instruction was in charge of training more (or ALL) office managers, the practice would be
    most certainly more widespread.

    This procedure is a common, every-day thing. There are many treatment options available, but the practitioner at this office chose what he/she believed to be the best, state-of-the-art option, really without discussion with regard to cost. Pretty much, "This what we are going to do,and it will cost you this much."
    If the practitioner is actively involved, this could get to be a real mess.

  25. #25
    BF Risk Manager
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    I do healthcare risk management for a living. Noting the OPs comments as to a 'head office', this makes me think that he was involved with a larger healthcare system. Every such system has what is a called a 'compliance officer' whose job it is to look into such matters. You can contact that person, often anonymously if you wish, and express your concerns there. They will likely work with the billing and coding people to determine the merits of your concern and if any corrective action or re-training needs to take place. Look on the system's website to see how to contact the compliance officer.

    Having said this, medical coding and billing is a rats nest. The insurance companies game the system to try and decrease reimbursement to the providers, and the providers game the system to try and increase the reimbursement. There are often multiple yet entirely ethical and legal ways to code a given encounter or procedure. The choice of any particular one of these multiple ways does not necessarily mean that anything shady is going on. After the provider submits the billing code for a given encounter or procedure, the billing software and/or the billing clerks get their hands on it, and can make all sorts of changes according to the requirements of a given insurance plan or upcoding or downcoding.

    Thinking that the office manager or provider is somehow personally profiting from this is very unlikely, unless they are submitting 'ghost claims' for patients, encounters or procedures that never actually happened.
    Regards, MillCreek
    Snohomish County, Washington USA

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