Medical Billing Fraud

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Medical billing fraud usually begins with a letter. Today I brought the mail in as usual, but unexpectedly Kurt opened up what was soon discovered to be a bill from a medical provider that we used. Kurt as usual handed the bill over to me and said “what is this, you take care of this.” He does not keep track of these things and as in most families I (the wife) am the record keeper and bill payer. I reviewed the bill and was SURPRISED to see that I was being charged for the entire procedure, even though I was informed that our Health Insurance company would be responsible for the claim. I immediately called the service provider to inquire why I was receiving this bill and I was told by the medical provider that our health insurance company indicated that we had not met our deductible. I told the medical provider that we do not have a deductible and that prior to the procedure being done we were informed by the medical provider that they accepted our insurance and a copay was requested and paid. The medical provider indicated that they were an In-network provider, thus the acceptance of the co-payment.
Kurt and I were outraged by getting a SURPRISE bill because we were told that this was an in-network procedure. Outrage then turned to action. I am fortunate and so are you, my readers, because one of Kurt’s areas of expertise is executive level preparation and training to detect fraudulent medical billing practices. Kurt is trained to implement complaints, appeals and grievance procedures with medical insurance companies, including HMO’s ,MCO’s and other managed long term care plans (MLTC). shutterstock_306283364
These are the 10 steps that have been taken to date to resolve this issue of what we consider to be fraudulent medical billing.
1. Call the Medical Provider and dispute the bill (claim).
2. Call your health insurance provider complaint department:
• Their purpose is to try to resolve any complaints you have with both in-network and out-of-network providers. You as the consumer have a right to make a formal complaint and to request an appeal of any medical bill that you feel misrepresents any procedure that was done, including overbilling or any allegation of fraudulent billing. Kurt recommends that you formally request of the complaint/grievance representative that they document this encounter as a formal complaint/grievance.
3. Ask for the Complaint/Grievance Representative’s employee identification number. You have to be able to document the person, date and time you logged your complaint.
4. Clearly inform the complaint/grievance representative of your allegation of fraud and or problematic billing.
5. Documentation becomes more complete if you include these simple steps:
• Always try to complete documentation requirements by answering the following questions: Who, What, When, Where, How and Why, (the why is often the most difficult and most subjective). If you prepare your documentation to answer those questions you can be confident that 95% of your documentation requirements will be accurate and fulfilled.
6. Get the reference number for your complaint.
7. There are different levels of grievance complaints that you can request from Standard to Emergency Expedited levels. The health insurance carrier is required to respond in a specific time frame based upon the level of complaint that you have made. Anywhere between 45 days to as little as 24 hours of turn around time back to the consumer.
8. The Health Insurance carrier may recommend that you to follow the ‘Information for Members in New York Insurance Plans: Emergency Services and Surprise Bills’
Click on link for steps to follow: Info_ Mem_NY_InsurancePlans_EmergencyServices_SurpriseBills
9. DON’T PAY THE BILL! If you feel you have been fraudulently billed or have been surprised by a bill
10. ACT IMMEDIATELY, DO NOT WAIT!

Our next steps; we are going to follow the Emergency Services and Surprise Bills protocol. We may choose to contact the NYS Attorney General Office to inform them of our allegation of Medical Billing Fraud if we need to take that step. This will be contingent on whether or not this SURPRISE bill is resolved appropriately. Stay tuned!

Special thanks to Kurt H. Leggard, R.N. who helped co-write this article. Kurt is a Registered Nurse, Consultant and a specialist in Long Tem Care, Medicaid Services and Heath Care Grievances, Complaints and Appeals.

New York State Department of Health Medical Fraud Link: www.health.ny.gov

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