ER E&M upcoding

Lisa Cato

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We have a provider(Hospital) that routinely upcodes Emergency room E&M codes using 99285. Documentation clearly does not support the billing of the code and the provider refuses to lower the code or the charges. The provider in turn bills the patient for the charges since we, the auto insurance company won't pay for the services/treatment where documentation isn't supporting the billing. How can this be handled appropriately? We don't want the patient balance billed for a service that wasn't rendered. Is there an organization where a formal complaint can be filed?
 

mitchellde

True Blue
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Columbia, MO
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to bill for services not provided is fraud, check with you states attorney generals office or if you have a state board of healing arts or the equivalent.
 
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