Oh Yikes!

I recently took my three daughters to the optometrist.  Our health insurance doesn’t include vision, and we had added it for 2019.  My husband had been to this optometrist in January.  The doctor is someone we have known just a tad socially, and we really like him.  He’s funny, he puts the kids at ease, and you can just really tell that he enjoys himself no matter what he is doing.

When I made the appointment, the scheduler assured me that she could attach my husband’s vision insurance information to the girls’ accounts.  Obviously, I know that most systems will enable the creation of a “Responsible Party” account, which would make this easy.  The day of the appointment, they called to tell me that my medical insurance would not cover the visits.  I reminded them of the vision coverage (completely different insurer), and they told me on the phone that they had now connected the accounts.

While we were there, they asked me for a copy of our medical insurance cards.  I again reminded them of our vision coverage.  They told me that this was just in case.  I know that there are things that could be found that would fall under medical, so I complied.

The appointments then went off without a hitch.  No one had issues, and no one needed to be dilated.  An hour later, we were back on our way.

About two weeks later, I received an EOB from our medical insurance provider stating that these service weren’t covered.  This was only for one of my children.  I simply sighed and told my husband that it was no big deal.  They had just filed it incorrectly.  The next morning, when I woke up, I started thinking of it again, and I realized that we hadn’t be credited with our $10 copay.  The credit card bill had come at the same time, so I knew that the charge had gone through.

Now that is an anomaly.

So, before I called the office, I took some other steps:

  1. I contacted the vision insurance company to be certain that the claim had been filed and paid.  It had been.  The visit was on Thursday, October 17.  The claim had been filed, accepted, and paid by Friday, October 18.
  2. I contacted the medical insurance company to make sure that this was only one of my kids and not all three.  It was.  They also told me that the claim had been filed on Friday, October 18, and processed on Tuesday, October 22.  (My investigation occurred on Thursday, October 31.)
  3. Then I called my favorite insurance specialist at one of the dental practices I work with.  I just wanted to see if she thought that I might be missing something.  She found this to all be very very strange.
  4. Then I called the office.
    1. I spoke with a very nice young lady who said, “Well that’s strange!  I don’t even show a claim with the medical insurance in our computer!  I’ll have our insurance person call you back once she figures out what is wrong.”  Red flag #1.  When using EMR’s there is simply no reason the claim wouldn’t be in the system, even a rejected claim.  If something had been messed up, there should be notes that explain what happened so that the patient could be informed if they called.
    2. The insurance person called me back 14 minutes later.  She simply told me that everything was taken care of and our vision insurance had paid.  There is simply no way that she found out in 14 minutes what happened.  Anyone who knows what goes into calling and working with medical insurance companies knows that.  Red flag #2.
  5. At this point, I emailed the doctor.

He called me an hour or so later, and I walked him through what I had observed.  I reminded him that the vast majority of his patients would walk away thinking how easy they had been to work with, and how fast they fixed the problem.  He and I talked through it all, then he asked, “how could someone profit off of this scam if the money goes directly into my account?”

Great question.

If this claim happened to get paid, which happens, let’s say the EOB came in to the office on a Tuesday.  The payment then needs to be posted to someone’s account.  So, Sally reworks checks or cash payments throughout the day to pay out to her instead of the practice.  She then distributes the extra insurance payment to those accounts from which she is stealing to cover her theft.  The accounts are showing payment, and my daughter’s account is not showing a credit. Sally’s bank account is showing the nefarious profit.

The scary part is, this could have been going on for years, and the doctor is the one the insurance company (and the legal system) will hold responsible.  This sort of fraud is very very difficult to catch.  By using proper systems and appropriately separating duties, you can prevent it.

And it is always easier to prevent that to catch insurance fraud.

Don’t let this story scare you!  Take this opportunity to empower yourself and your practice by implementing systems that will help protect your practice from fraud and embezzlement.

Want to learn more?  Email me at Becky@DanielsBusinessSolutions.com.

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