Is it Fraud?

Is it fraud?

An adventure in medical billing by Jordan Levin

Fraud is a term thrown around even when there is none.  Often when a party is mad about the outcome of a situation.  But when there is fraud, a violation of contracts, laws, rules, or regulations.  It requires intent, purpose, and distinction from errors or unintentional mistakes.  So, is it fraud when an insurance company denies a claim in error.  The answer is maybe, maybe not.  Questions must be asked.  This is not legal advice, I am not a lawyer, but it is general a good idea to check your facts before jumping to conclusions.  What questions should be asked is harder to figure out.  Did the insurance deny on purpose when the plan covers the service?  Did the plan ignore the pre-auth?  Did the plan state the service is out-of-network when it was in-network, or vice versa?  These are the types of questions to ask to start.  From there you can formulate a game plan on appeals.  But what if the appeals don’t work or this is a surprise bill?  What if no matter what you try the insurance keeps denying a claim you are sure is covered and should be paid? 

These are questions that have been asked for decades about insurance denials or underpayments.  Laws change, plans change, providers network status changes, the patients are different, but process matters.

So, in the spirit of “just asking questions,” I am going to lay out some facts and let the reader decide for themselves on the facts that are recorded.

1.        The doctor is out-of-network

2.        The patient saw that doctor at an In-Network hospital in New York state.

3.        The doctor rendered care in good faith according to hospital rules along with state and federal laws.

4.        A claim was filed to the insurance company for the patient for reimbursement to the doctor with a charge amount of $8,000.

5.        The plan pays the doctor a small amount of $400, and claims the doctor is IN-Network. 

6.        The doctor calls the plan and gets a call center in another country.  After 45 minutes of hold and 20 minutes of “please hold” and “I am reviewing” the plan representative reads the same information the doctor already has and claim to have no access to any other information and that is all they can do.

7.        The doctor now appeals the low payment and incorrect In-Network designation in writing.

8.        The plan replies that after review they have found that the claim processed correctly.

9.        The doctor appeals again.

10.  The plan replies that after review they have found that the claim processed correctly.

Is this fraud? 

Let’s add some more to this, shall we?

11.  The provider, knowing they are OUT-OF-NETWORK checks the patient’s coverage and finds this is a self-funded employer sponsored health benefits plan and therefore files a federal no surprises act open negotiation notice to the plan.

12.  The plan replies to the provider that the claim for service is not eligible for the federal no surprises act.

Is this fraud?

How about we add a little more to this?

13.  The provider files the dispute with the federal no surprises act portal, and also sends the dispute initiation to the payer as the rules require.

14.  The payer does not reply.

15.  After a back and forth the dispute is assigned to an Independent Dispute Resolution Entity (IDRE) at random.

16.  The payer objects to the federal no surprise act dispute, claiming the provider is IN-NETWORK.

17.  The IDRE sends a development email to the provider asking about their network status and any other additional information that would help them determine if the claim is eligible for the no surprises dispute process.

18.  The provider submits to the IDRE proof they are OUT-OF-NETWORK in the form of emails from the payer confirming there is NO CONTRACT for the provider with the plan.  The provider also has the online network directory for the plan which does NOT show the provider listed.

Is this fraud?

Just a little bit more?

19.  The dispute moves forward and the IDRE rules in favor of the provider. 

20.  The plan objects again, for the same reason.

21.  The IDRE again asks the provider for proof they are OUT-OF-NETWORK.

22.  The decision is overturned, the IDRE rules the provider’s claim was ineligible because the plan stated the provider is IN-NETWORK.

Is this fraud?

Any more facts to add?

23.  The provider calls and emails the IDRE.  Calls go into voicemail and are not returned, and emails are not replied to, receive email blocked messages, or receive a form letter reply.

24.  The provider files complaints with the No Surprises Help Desk email and to the complaint portal.

25.  The provider waits, and waits, and waits.

26.  Months go by and the provider still waits and waits.

27.  The IDRE finally replies that according to Centers for Medicare and Medicaid (CMS) guidance the provider cannot ask them to reopen the dispute, that only the IDRE can request to reopen the dispute or CMS itself can reopen it.

28.  Left with a small payment, and no reply from the CMS, the doctor contemplates balance billing the patient for the rest of the bill, $7,600.

Is this fraud?  What would you do as the doctor?  What would you do as the patient who gets a $7,600 bill months later?  Are your enjoying your adventure in medical billing?