Wiki Couple of case sceneros, are they fraud?

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Wenehoka

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I have a couple case sceneros I'd like some opinions or thoughts on, if they would be considered fraudulent. It concerns a friend of mine, and I feel they are or at least unethical, but my friend was told they weren't by another friends office manager she spoke to about it. She is fairly young and has only been working as a medical receptionist for a few years with this one office.

A supervisor has been over the practice for only a short period of time. (About 2-3 years) The past few months she has been working the aging reports, and having the office clerks sending out statements.Some/Most of the claims are well past timely filing limit. From 1 to 7 or 8 years or even older. Unless a patient calls in and says they have Medicaid 2nd, and state they can't afford to pay. They are billed until they pay. If they do call in, the office clerks are to tell them they will need to come in with their card to show proof (alot of the patients live hours away) and only then will she provide a write off. If they do not do this, she says they are responsible for the balance and collects from them.

None have a ABN on file, in almost all cases the patients were not verbally notified or there is nothing noted in their accounts to show that they were, told the practice is a non-par. And again alot of the claims are aged by two years or more.

Also the office clerks are not to enter the Medicaid card (in inactive status)into the patient account to show reference for check in, check out or billing that the patient has medicaid secondary even just for informational purposes.

The 2nd scenero...
A clerk has a patient call in to pay her bill. This patient has Cigna coverage only, she has been paying religiously on a large surgical bill for the past few months. The office clerk finds when she pulls up the account it was showing a insurance credit balance of over $5,000. And a patient credit balance of $75.00. The clerk remembers this was an account that she herself had found the charges were actually billed out twice a couple of months ago and had already brought it to the supervisors attention, and at that time the supervisor told her to contact Cigna to recoup one of the payments, the clerk did... But clearly the patient had been continuing to recieve a statement and pay payments. Even though there is a credit balance in the system.

The clerk placed the patient on hold, and consulted with the supervisor, and was told "tell the patient the balance had been satisfied." Then continues to tell her that she "did not need to tell the patient she had a credit balance, nor that the surgery was billed out twice. Just that she did not owe anything else."

The patient understandably confused, asked for a print out of the fiancial history for her records. So the clerk, sent the patient a copy, and it shows the patient credit balance as well as the insurance credit, so the patient will see she is owed a refund.

But am I wrong thinking the supervisor is committing fraud or at the very least extremely shady? This is only 2 situations of several others, she has confided in me about. I'd just like to hear some thoughts on the best way to advise her.

Thanks for taking the time to read. I know it's lengthy.
 
Does no one have a opinion or advice?

Wenehoka said:
I have a couple case sceneros I'd like some opinions or thoughts on, if they would be considered fraudulent. It concerns a friend of mine, and I feel they are or at least unethical, but my friend was told they weren't by another friends office manager she spoke to about it. She is fairly young and has only been working as a medical receptionist for a few years with this one office.

A supervisor has been over the practice for only a short period of time. (About 2-3 years) The past few months she has been working the aging reports, and having the office clerks sending out statements.Some/Most of the claims are well past timely filing limit. From 1 to 7 or 8 years or even older. Unless a patient calls in and says they have Medicaid 2nd, and state they can't afford to pay. They are billed until they pay. If they do call in, the office clerks are to tell them they will need to come in with their card to show proof (alot of the patients live hours away) and only then will she provide a write off. If they do not do this, she says they are responsible for the balance and collects from them.

None have a ABN on file, in almost all cases the patients were not verbally notified or there is nothing noted in their accounts to show that they were, told the practice is a non-par. And again alot of the claims are aged by two years or more.

Also the office clerks are not to enter the Medicaid card (in inactive status)into the patient account to show reference for check in, check out or billing that the patient has medicaid secondary even just for informational purposes.

The 2nd scenero...
A clerk has a patient call in to pay her bill. This patient has Cigna coverage only, she has been paying religiously on a large surgical bill for the past few months. The office clerk finds when she pulls up the account it was showing a insurance credit balance of over $5,000. And a patient credit balance of $75.00. The clerk remembers this was an account that she herself had found the charges were actually billed out twice a couple of months ago and had already brought it to the supervisors attention, and at that time the supervisor told her to contact Cigna to recoup one of the payments, the clerk did... But clearly the patient had been continuing to recieve a statement and pay payments. Even though there is a credit balance in the system.

The clerk placed the patient on hold, and consulted with the supervisor, and was told "tell the patient the balance had been satisfied." Then continues to tell her that she "did not need to tell the patient she had a credit balance, nor that the surgery was billed out twice. Just that she did not owe anything else."

The patient understandably confused, asked for a print out of the fiancial history for her records. So the clerk, sent the patient a copy, and it shows the patient credit balance as well as the insurance credit, so the patient will see she is owed a refund.

But am I wrong thinking the supervisor is committing fraud or at the very least extremely shady? This is only 2 situations of several others, she has confided in me about. I'd just like to hear some thoughts on the best way to advise her.

Thanks for taking the time to read. I know it's lengthy.
Click to expand...
 
Website for reporting

I am not very familiar with all compliance ins and outs yet, but I would simply suggest this person contact AHCA and let them advise him/her. It is probably best to allow them to investigate and take care of the legality issues. Here is their website you can pass along. It's good to be on our toes about these things to protect patients and our healthcare system. Best of luck to you all and kudos for looking out for fraud! **EDIT: my apologies, but this website is only for Florida. I would check for where to report healthcare fraud in your state.

https://ahca.myflorida.com/Executive/Inspector_General/complaints.shtml
 
Fraud is defined as the intentional misrepresentation of information (and in the context of medical billing usually pertains to false information submitted on claims about the nature of services rendered), so is probably not the right term to apply to the situations you are describing. This sounds like just very sloppy practice management and poor customer service. But the practice could potentially be in violation of other laws and/or their contractual agreements with payers.

Most states have limitations on collection of debt and it may not be appropriate to be billing or refusing to write off accounts that are 7 or 8 years aged, but you would need to be familiar with the laws in the state where this practice is located. Retaining credit balances can also be a compliance issue but again, this would depend on the specific circumstances, the state laws and the relationship that the provider has with the payer. Certainly for government payers, retaining overpayments can be a serious issue that may incur severe penalties, and there are also strict regulations about when patients may be balance billed.

The situations you've described certainly do sound inappropriate at best, and at worst could be crossing legal and compliance lines, but since the rules for how much and how patients may be billed are complex and vary greatly depending on the circumstances so I would be cautious about jumping to conclusions without first-hand knowledge of the practice's books and the details of the individual cases. Perhaps a good place to start would be to have your friend get more familiar with Medicare and your state's Medicaid rules - there is a lot of good information available on the web sites. Usually the Medicaid plans will have a provider manual that will have a chapter specifically spelling out the guidelines for when patients may be billed for services. Another good resource might be your state government's insurance commissioner and/or consumer protection bureau.
 
Last edited:
You are not able to balance bill a patient for a covered service. If there is a credit balance the patient should be refunded . Those accounts should have been written off previously if there was no continuous follow up. You also by law cannot balance bill a medi-medi patient for a covered service. Medicare usually allows more than Medi-Cal, so if there is no share of cost they should not pay anything especially when medi-cal was never billed. Medi cal will never pay more than the medicare allowed and they have a timely filing limit. As far as fraud, I am not sure if that would fall undr that.



Wenehoka said:
I have a couple case sceneros I'd like some opinions or thoughts on, if they would be considered fraudulent. It concerns a friend of mine, and I feel they are or at least unethical, but my friend was told they weren't by another friends office manager she spoke to about it. She is fairly young and has only been working as a medical receptionist for a few years with this one office.

A supervisor has been over the practice for only a short period of time. (About 2-3 years) The past few months she has been working the aging reports, and having the office clerks sending out statements.Some/Most of the claims are well past timely filing limit. From 1 to 7 or 8 years or even older. Unless a patient calls in and says they have Medicaid 2nd, and state they can't afford to pay. They are billed until they pay. If they do call in, the office clerks are to tell them they will need to come in with their card to show proof (alot of the patients live hours away) and only then will she provide a write off. If they do not do this, she says they are responsible for the balance and collects from them.

None have a ABN on file, in almost all cases the patients were not verbally notified or there is nothing noted in their accounts to show that they were, told the practice is a non-par. And again alot of the claims are aged by two years or more.

Also the office clerks are not to enter the Medicaid card (in inactive status)into the patient account to show reference for check in, check out or billing that the patient has medicaid secondary even just for informational purposes.

The 2nd scenero...
A clerk has a patient call in to pay her bill. This patient has Cigna coverage only, she has been paying religiously on a large surgical bill for the past few months. The office clerk finds when she pulls up the account it was showing a insurance credit balance of over $5,000. And a patient credit balance of $75.00. The clerk remembers this was an account that she herself had found the charges were actually billed out twice a couple of months ago and had already brought it to the supervisors attention, and at that time the supervisor told her to contact Cigna to recoup one of the payments, the clerk did... But clearly the patient had been continuing to recieve a statement and pay payments. Even though there is a credit balance in the system.

The clerk placed the patient on hold, and consulted with the supervisor, and was told "tell the patient the balance had been satisfied." Then continues to tell her that she "did not need to tell the patient she had a credit balance, nor that the surgery was billed out twice. Just that she did not owe anything else."

The patient understandably confused, asked for a print out of the fiancial history for her records. So the clerk, sent the patient a copy, and it shows the patient credit balance as well as the insurance credit, so the patient will see she is owed a refund.

But am I wrong thinking the supervisor is committing fraud or at the very least extremely shady? This is only 2 situations of several others, she has confided in me about. I'd just like to hear some thoughts on the best way to advise her.

Thanks for taking the time to read. I know it's lengthy.
Click to expand...
 
If the patient has a credit on the account, it is absolutely dishonest and probably illegal to keep it. The doctor should be reported to your state's Board of Medicine.

By the way, check your state's statutes, and you will probably find something concerning unreturned credit balances, unclaimed property, or something of the sort.
 
thomas7331 said:
Fraud is defined as the intentional misrepresentation of information (and in the context of medical billing usually pertains to false information submitted on claims about the nature of services rendered), so is probably not the right term to apply to the situations you are describing. This sounds like just very sloppy practice management and poor customer service. But the practice could potentially be in violation of other laws and/or their contractual agreements with payers.

Most states have limitations on collection of debt and it may not be appropriate to be billing or refusing to write off accounts that are 7 or 8 years aged, but you would need to be familiar with the laws in the state where this practice is located. Retaining credit balances can also be a compliance issue but again, this would depend on the specific circumstances, the state laws and the relationship that the provider has with the payer. Certainly for government payers, retaining overpayments can be a serious issue that may incur severe penalties, and there are also strict regulations about when patients may be balance billed.

The situations you've described certainly do sound inappropriate at best, and at worst could be crossing legal and compliance lines, but since the rules for how much and how patients may be billed are complex and vary greatly depending on the circumstances so I would be cautious about jumping to conclusions without first-hand knowledge of the practice's books and the details of the individual cases. Perhaps a good place to start would be to have your friend get more familiar with Medicare and your state's Medicaid rules - there is a lot of good information available on the web sites. Usually the Medicaid plans will have a provider manual that will have a chapter specifically spelling out the guidelines for when patients may be billed for services. Another good resource might be your state government's insurance commissioner and/or consumer protection bureau.
Click to expand...
I have a question I am hoping you can answer. I am working through credit balances that were created over the last few years, but never resolved. I am refund patients regardless of the age of account. I have also been processing refunds for accounts where patient has a primary that pays, then Partnership or Medi-cal is balanced billed with EOB, but they also pay as primary. Apparently Partnership was not aware that the patient had a primary ins. I have quite a few of these and still working through the credits. Most are insurance. Our billing has been outsourced, so I am cleaning up, so to speak. The only accounts I have left are credit balances. I will continue to refund as many as I need to, just wondering if you had any ideas about these credits when I discover them, Partnership has not requested a refund. Thank you for any help you are able to provide.
 
Hello,

I am currently helping a small private practice and came across a comment from the biller saying that the EOB of the patient indicates the following: "members cannot be balanced billed for certain claims." Has anyone encountered this language? What does it mean, and how do I ensure the patient has not been balanced billed?
Thank you.
 
elvitaisenia@yahoo.com said:
Hello,

I am currently helping a small private practice and came across a comment from the biller saying that the EOB of the patient indicates the following: "members cannot be balanced billed for certain claims." Has anyone encountered this language? What does it mean, and how do I ensure the patient has not been balanced billed?
Thank you.
Click to expand...
While the statement is certainly true, it is also incredibly vague without knowing more about "certain claims." I don't recall ever seeing that on an EOB, but I'm also not in the habit of reading every line of small print or disclaimers.
Examples of situations when members cannot be balance billed:
- Provider is participating with insurance and the contract prohibits balance billing.
- Services were provided by an out of network provider while patient was admitted to an in network facility.
- Services were provided by an out of network provider where the patient did not have a choice of provider (like pathologist).
- Other services falling under the federal No Surprises Act.
The provider's billing system would show whether or not the patient was balance billed for a particular claim.
 
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