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INSURANCE FRAUD?

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  • Raynea
    I have a question regarding making payment arrangements with patients. The doctor does a lot of different things from treating the case as cash and not
    Message 1 of 3 , Dec 9, 2008
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      I have a question regarding making payment arrangements with patients.
      The doctor does a lot of different things from treating the case as
      cash and not submitting to insurance to waiving deductibles or giving
      them in network benefits when we are out of network etc.... My
      question is isn't this considered insurance fraud to bill the insurance
      company one amount and charge the patient something different? The
      doctor just sold the practice to someone else and I don't want to get
      into the same habit of adjusting so much of the income each month? Any
      advice would be greatly appreciated! Any info on what you are allowed
      to do with the insurance companies would be great also.

      Thanks,
      Raynea
    • Lin
      Yes that is absolutely fraud and not to scare you but the laws regarding fraud and abuse can and do apply to all person(s) who knowingly submit claims, even if
      Message 2 of 3 , Dec 9, 2008
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        Yes that is absolutely fraud and not to scare you but the laws regarding
        fraud and abuse can and do apply to all person(s) who knowingly submit
        claims, even if you are an employee your liability is the same. Since you
        are "aware" you are in a very tight spot here so be careful. I would
        schedule a meeting to talk with your new employer and I might even be
        inclined to suggest you document these types of things in the future as well
        as your talk and discussion with the new employer so that you have enough to
        cover your ass. A good rule of thumb is to never submit a claim you suspect
        or know is fraudulent, for example if the provider is routinely billing
        insurance for a fee and charging another fee to the patient and you know
        this is going to happen (again..routinely) don't participate at all, your
        liability in this is the same as the doctors. I have seen office managers
        get into just as much trouble because of fraud as the doctor. I even know
        one who really did not know what she was doing was wrong but was prosecuted
        anyway because she "should have known it was wrong"

        This involved her filing claims while the doctor was on vacation (on his
        direct orders to do so). Crazy yes..but it happens.





        Linda Walker

        Practice Managers Resource & Networking Community
        <http://www.billerswebsite.com> http://www.billerswebsite.com
        A division of K&L Media, LLC
        <http://www.klmediallc.com> http://www.klmediallc.com

        Website Design & Management for the Medical Services Industry









        From: MedicalBillers@yahoogroups.com [mailto:MedicalBillers@yahoogroups.com]
        On Behalf Of Raynea
        Sent: Tuesday, December 09, 2008 10:55 AM
        To: MedicalBillers@yahoogroups.com
        Subject: [MedicalBillers] INSURANCE FRAUD?




        I have a question regarding making payment arrangements with patients.
        The doctor does a lot of different things from treating the case as
        cash and not submitting to insurance to waiving deductibles or giving
        them in network benefits when we are out of network etc.... My
        question is isn't this considered insurance fraud to bill the insurance
        company one amount and charge the patient something different? The
        doctor just sold the practice to someone else and I don't want to get
        into the same habit of adjusting so much of the income each month? Any
        advice would be greatly appreciated! Any info on what you are allowed
        to do with the insurance companies would be great also.

        Thanks,
        Raynea



        __________ Information from ESET Smart Security, version of virus signature
        database 3677 (20081209) __________

        The message was checked by ESET Smart Security.

        http://www.eset.com



        [Non-text portions of this message have been removed]
      • Melinda
        I m with Lin on this one! Melinda Brown, CMBS Ins Biller ... regarding ... submit ... Since you ... be ... future as well ... enough to ... suspect ... billing
        Message 3 of 3 , Dec 9, 2008
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          I'm with Lin on this one!

          Melinda Brown, CMBS
          Ins Biller

          --- In MedicalBillers@yahoogroups.com, "Lin" <italiandoll1967@...>
          wrote:
          >
          > Yes that is absolutely fraud and not to scare you but the laws
          regarding
          > fraud and abuse can and do apply to all person(s) who knowingly
          submit
          > claims, even if you are an employee your liability is the same.
          Since you
          > are "aware" you are in a very tight spot here so be careful. I would
          > schedule a meeting to talk with your new employer and I might even
          be
          > inclined to suggest you document these types of things in the
          future as well
          > as your talk and discussion with the new employer so that you have
          enough to
          > cover your ass. A good rule of thumb is to never submit a claim you
          suspect
          > or know is fraudulent, for example if the provider is routinely
          billing
          > insurance for a fee and charging another fee to the patient and you
          know
          > this is going to happen (again..routinely) don't participate at
          all, your
          > liability in this is the same as the doctors. I have seen office
          managers
          > get into just as much trouble because of fraud as the doctor. I
          even know
          > one who really did not know what she was doing was wrong but was
          prosecuted
          > anyway because she "should have known it was wrong"
          >
          > This involved her filing claims while the doctor was on vacation
          (on his
          > direct orders to do so). Crazy yes..but it happens.
          >
          >
          >
          >
          >
          > Linda Walker
          >
          > Practice Managers Resource & Networking Community
          > <http://www.billerswebsite.com> http://www.billerswebsite.com
          > A division of K&L Media, LLC
          > <http://www.klmediallc.com> http://www.klmediallc.com
          >
          > Website Design & Management for the Medical Services Industry
          >
          >
          >
          >
          >
          >
          >
          >
          >
          > From: MedicalBillers@yahoogroups.com
          [mailto:MedicalBillers@yahoogroups.com]
          > On Behalf Of Raynea
          > Sent: Tuesday, December 09, 2008 10:55 AM
          > To: MedicalBillers@yahoogroups.com
          > Subject: [MedicalBillers] INSURANCE FRAUD?
          >
          >
          >
          >
          > I have a question regarding making payment arrangements with
          patients.
          > The doctor does a lot of different things from treating the case as
          > cash and not submitting to insurance to waiving deductibles or
          giving
          > them in network benefits when we are out of network etc.... My
          > question is isn't this considered insurance fraud to bill the
          insurance
          > company one amount and charge the patient something different? The
          > doctor just sold the practice to someone else and I don't want to
          get
          > into the same habit of adjusting so much of the income each month?
          Any
          > advice would be greatly appreciated! Any info on what you are
          allowed
          > to do with the insurance companies would be great also.
          >
          > Thanks,
          > Raynea
          >
          >
          >
          > __________ Information from ESET Smart Security, version of virus
          signature
          > database 3677 (20081209) __________
          >
          > The message was checked by ESET Smart Security.
          >
          > http://www.eset.com
          >
          >
          >
          > [Non-text portions of this message have been removed]
          >
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