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A Matter of Misrepresentation

Insurance companies are recouping payments for anything from differences in opinion and typos to legitimate fraud without any time limit.  These requests can reach the hundreds of thousands of dollars and span 10 years.  Our new bill caps this at 18 months, yet the insurance companies want us to add just one more exception: no time limit if the insurer feels that there was “misrepresentation.”  Well, considering they view nearly everything as misrepresentation that would give the insurer the ability to ignore the time limit whenever they wanted.  Here are some actual cases we’ve seen at the office this year that would be problematic:

Case #1: It isn’t always clear to our doctors which code to bill for.  Taping for example, falls in the “surgical” section of the CPT code book, and many times our docs will be told by the insurer that they should avoid using surgical codes.  Payors will rarely definitively state which code should be used, but they may give examples of what codes other providers “might” use.  We consistently tell our doctors to “use the code that most accurately represents the service performed” despite what the insurance company told them.  This often leads to more hassles up front but lowers their risk of being recouped later.  Another popular coding example of this is the differences between manual therapy (more focused on a particular ailment) and massage therapy.

Case #2: Sometimes our docs are doing things that are specifically allowed law and covered by a majority of insurance companies, but not all.  Delegation of massage services to trained staff is one example. Doctors are acting legally and doing what they believe to be correct, yet they will get a recoupment letter spanning several years and exorbitant amounts of money all claiming “misrepresentation.”  The insurance company claims that the provider misrepresented who was doing the service, or that a contractually acceptable diagnosis technique was used.  Delegation of supervised services to trained staff is statutorily allowed in Illinois by our state legislature (and used regularly by medical doctors).   Outdated contracts not keeping up with current diagnosis techniques leads to similar problems as well.

Case #3: Sometimes a patient provides poor information to the doctor, such as confusing which insurer is primary, or that the situation might later turn into a personal injury or workers’ compensation case. Years later the insurer may just recoup the money from the doctor, opposed to the patient or other insurance companies.  The issue was never with the doctor, yet it is claimed that he misrepresented the situation.

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