Medical Billing Coding - Patient Insurance Claim , cpt, codes
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Thread Topic: Patient Insurance Claim
Topic Originator: Bill
Post Date May 16, 2014 @ 1:52 PM
Patient Insurance Claim


Bill
May 16, 2014 @ 1:52 PM Reply  |  Email Friend   |  |Print  |  Top

Hi everyone,

Great forum! I'm impressed by how knowledgeable and insightful everyone is.

I am a provider and have a question that might be slightly off topic, but I hope you will be kind enough to help me regardless.

I am a psychotherapist and provided one of my patients with a 1500 form with my required information and instructed him to make photocopies of the form to fill in with specific dates of service to submit to his insurance reimbursement (I'm an out of network provider).

I do not usually receive EOBs from his insurance company but recently did receive one because a claim had been denied due to the client making an error in the CPT code when filling out the form. I saw also from the EOB that he had submitted for reimbursement dates of service during which we never met.

Obviously this is fraudulent and could get him and/or me in a lot of trouble. I'm so worried :(
In figuring out how to handle this situation, I was wondering -- when do health insurance companies usually investigate for fraud? If the client continues to submit false claims for reimbursement, will the insurance company simply start denying the claims? Or will they launch a full investigation if they suspect fraud? What would the investigation entail?

Any information you could provide would be greatly appreciated. Thank you!

Bill



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