kbrasington
Contributor
This might belong in the coding forum, but I'm just going to post this here.
So something has come up at my place of employment and I'm wondering if this could be insurance fraud. I'm certain it is, but I'm looking for other insight.
I was reviewing some A/R and we have some really old unpaid claims. I found something from 2015 that was denied because of the diagnosis codes not being covered. So when I called the payer to ask for details, they told me that the diagnosis codes we billed were 643.03 - mild hyperemesis gravidarum (yes these are ICD-9) and 643.10 - hyperemesis gravidarum with metabolic disturbance. The patient does not have any coverage for maternity services, which includes anything related to pregnancy or a complication of pregnancy. That is why they denied the claims. We had been able to obtain pre-cert though, so I asked them what dx codes they had tied to the pre-cert. I was told 401.9, which is unspecified hypertension.
I'm not sure why we gave them the HTN diagnosis though. I looked through all the clinical notes and it was all about how the patient was throwing up non-stop and was malnourished and had anemia and all kinds of problems related to the vomiting, which was a complication of the pregnancy. I couldn't find anything about HTN though'; in fact, most of the BP readings for the patient were normal or low.
My manager called the insurance company back and asked what we could do about this because we "billed the wrong dx code." The rep advised us to send an appeal with the correct dx codes. My manager told me to do it. I told her that the medical records reflected that the patient was being seen for pregnancy complications, and because of this, her services were noncovered. She told me to not worry about what the records said, and to just change the codes and rebill.
As far as the pre-certs are concerned, I have no idea where we got HTN from and why that would have been the primary dx for a home health agency to be seeing such a patient. I suspect we didn't have all the information from when we checked the patient's benefits, and in order to quickly obtain an auth, we just used a generic code like HTN. Not the right thing to do, but I'm guessing that's what we did until we were able to have someone go back and code the entire chart properly...again, this was all the way back in 2015, so the person who obtained the auth doesn't work there anymore.
So my question is, would this be fraud? I don't want to do this and I want to tell the upper management that if the payer comes back and requests medical records, we are screwed, as pregnancy-related services are not a covered benefit and we took the pregnancy codes off the claim form to get around that denial. I am also very scared that management will get mad at me and possibly fire me. Anyone have any insight or can relate? I really need help!! :'(
So something has come up at my place of employment and I'm wondering if this could be insurance fraud. I'm certain it is, but I'm looking for other insight.
I was reviewing some A/R and we have some really old unpaid claims. I found something from 2015 that was denied because of the diagnosis codes not being covered. So when I called the payer to ask for details, they told me that the diagnosis codes we billed were 643.03 - mild hyperemesis gravidarum (yes these are ICD-9) and 643.10 - hyperemesis gravidarum with metabolic disturbance. The patient does not have any coverage for maternity services, which includes anything related to pregnancy or a complication of pregnancy. That is why they denied the claims. We had been able to obtain pre-cert though, so I asked them what dx codes they had tied to the pre-cert. I was told 401.9, which is unspecified hypertension.
I'm not sure why we gave them the HTN diagnosis though. I looked through all the clinical notes and it was all about how the patient was throwing up non-stop and was malnourished and had anemia and all kinds of problems related to the vomiting, which was a complication of the pregnancy. I couldn't find anything about HTN though'; in fact, most of the BP readings for the patient were normal or low.
My manager called the insurance company back and asked what we could do about this because we "billed the wrong dx code." The rep advised us to send an appeal with the correct dx codes. My manager told me to do it. I told her that the medical records reflected that the patient was being seen for pregnancy complications, and because of this, her services were noncovered. She told me to not worry about what the records said, and to just change the codes and rebill.
As far as the pre-certs are concerned, I have no idea where we got HTN from and why that would have been the primary dx for a home health agency to be seeing such a patient. I suspect we didn't have all the information from when we checked the patient's benefits, and in order to quickly obtain an auth, we just used a generic code like HTN. Not the right thing to do, but I'm guessing that's what we did until we were able to have someone go back and code the entire chart properly...again, this was all the way back in 2015, so the person who obtained the auth doesn't work there anymore.
So my question is, would this be fraud? I don't want to do this and I want to tell the upper management that if the payer comes back and requests medical records, we are screwed, as pregnancy-related services are not a covered benefit and we took the pregnancy codes off the claim form to get around that denial. I am also very scared that management will get mad at me and possibly fire me. Anyone have any insight or can relate? I really need help!! :'(
