insurance wars! fraud and sloth

Again, while gearing up for a massive fight with a doctor, I remembered some good fights from the past.

In 1998 I got a notice from my insurance company that they weren’t going to pay a claim because the visit hadn’t been referred by our son’s PCP. I called the insurance company and said, “But we visited the PCP on that day, so how could we need a referral? And how would I get the PCP to refer herself?”

The CSR laughed. “You know what? The billing folks inverted two digits on the doctor’s code number. Instead of him seeing the pediatrician, they billed him for a visit to an anesthesiologist in West Bumpford.”

I said, “It was just a sore throat — he didn’t need anesthesia!” and we both had a good chuckle. I asked her to please fix the code, but she said she couldn’t do that, that the billing folks needed to resubmit the bill with the correct provider code and then they’d pay it.

I called the billing people (associated with the hospital) and explained that they had inverted two digits on the provider code, easy enough to do, and asked the billing person to please resubmit it.

She said, “No,” and that it wasn’t her problem if my insurance wasn’t going to pay.

I explained again that her department had made the error and my insurance company would be more than happy to pay the bill if she fixed it. She again refused.

Now,I could have gone to her supervisor. But instead I thanked her and got off the line.

I waited five minutes.

I called back and got her again. I said, “I just turned you in for insurance fraud.”

She said, “What? Why did you do that?”

I said, “Because you billed my insurance company for a visit for my son to an anesthesiologist in West Bumpford, and we never went there. You can’t prove we did. In fact, I can prove we weren’t there because at that very date and time, we were standing in his pediatrician’s office having an appointment for a sore throat.”

The billing person said, “Fine. Fine. I’ll resubmit the claim.”

“Thank you,” I said sweetly.

And that’s how Jane got her claim paid.