Training Primer - Medical Billing Physics

[Danni R.]

No way!!!! I mean--I knew of the fake accident scam by one person causing a collision, but the FRONT AND BACK CAR working as a team so you get it from both ends... Unbelievable.

(I used the expression "no way" as a shout out of surprise! I do believe you. It is crazy!).

I would hate for insurance companies to hike their prices yet again. It's already ridiculous. On top of it I happen to be lucky and nutty enough to own a few of the "finer" cars, since fine cars are just my thing. I love my Limited Edition Dodge Charger Daytona R/T, my big BIMMER (750 Li) and my Dodge Ram 1500 for the horses. My husband also is into nicer big cars, he has the Chrysler 300C (all wheel drive and the HEMI engine). And as the parents... well, so the son, who has a nice snazzy little Volkswagen Rabbit. Nice little thing. I pay the insurance on all.

Like so many, we, too, have worked very, very hard our entire lives to have a little fun now, as we mature in age. And while we don't allow ourselves any other of the common luxuries (e.g. a manicure, foot massage and painted nails every week, fishing, golfing, boating, yachting, parachuting, flying, or travelling the world, stuff like that) we love to take a spin in the car(s). Our little satisfaction and break away from work. An insurance rate hike would just leave a sour taste in my mouth, but if ANYONE were to pull a fake accident stunt on my limited ed Dodge Charger, which I have kept mostly in the garage and in mint condition, or my BMW baby, or even the truck, I will turn Jackell and Hyde on them. They will get to know my mean side, talk about some serious road rage then. Better not mess with the "Charger Lady".

Since it is not my field of expertise, I apologize, I cannot directly comment on the medical billing and health insurance part... I leave that to the next person. GOOD ADVICE, Steve:

1.  Verify, Verify, Verify the patient and their address.   (I just went to an appointment where someone was using my home address.  The practice never asked for any ID to verify the patient's information, so I was getting his medical bills, his debt collection agency phone calls and law firm letters)  Again, verify, verify, verify the patient, their insurance and their address.  If  a patient becomes indignant or says no, unless there is an emergency, you can ask the person to leave and not accept the person as a patient. 

2.  Submit claims for services that are truly provided. 

3.  All claims submitted must be 100% true, correct, and accurate and verified with the insurance company for benefits, authorizations or precertification. 

4.  Develop and follow your compliance plan as it regards to coding, billing, debt collection, verification of benefits and insurance, patient privacy, patient information protection and fraud prevention.




Over and out.

[Steve Verno]

Disclaimer,  I am not a lawyer. I am a biller and coder.  I do not provide any legal advice at any time.  This post is for training purposes only.  Names used are fictitious.  Any resemblance to real people or other fictitious names is coincidence. 


I was listening to the news regarding car insurance.  They are reporting high volumes of fraud associated with car accidents.  As a result, the insurance companies are requesting increases in premium fees. 

Mr. Magoo is driving his 1947 Hudson in Orlando.  He is the original owner of the car.  In front of him a car pulls into his lane just a few feet in from of Mr. Magoo.  The car applies their brakes causing Mr. Magoo to hit the car.  At the same time, there is a car right behind Mr. Magoo, they hit Mr. Magoo from behind.  This is a tactic some people use to file false claims.  This was a planned accident.  In the front and back car are 4 men in each car.  No one is seriously hurt.  The two fraud cars are covered through ABC Insurance. Florida's Personal Injury Protection Law allows $10,000 for injuries and loss of wages.

All 8 men go to see Dr Bones claiming back and neck pain.  Mr. Magoo goes to see Dr Detroit for neck and back pain as well.

Dr. Bones sends a claim to ABC Insurance for all 8 car occupants. Each occupant provides a real name on the policy but provides a fake home address.   Dr Detroit sends a claim to Mr. Magoo's insurance.  None of Dr Bones's patients return.  Over the next 4 months. Dr. Bones submits claims for each of the 8 patients even though they were never seen again.  When the $10,000 is exhausted, Dr Bones bills Mrs. Fields, Ronald McDonald, Flo, Bob Evans and Peggy who happen to have the address used by the car accident patients.  Each of these people call Dr Bones's office to state that they were never seen by Dr Bones, but his staff ignores their complaints and concerns.  When the bills arent paid, the accounts are sent to Dr Bones's aggressive debt collection agency.  They make many calls per day to each of these people in an attempt to get these people to pay the bill.  The debt is reported to the credit bureau. 

SO, how does physics work here?

You have 8 men planning an accident and working with a doctor to bill fake injuries and fake visits to the doctor. Per State law, there is $10,000 available per drivers and there might be coverage to cover the occupants.   The doctor takes some of the insurance payments and pays the men who caused the accident.  The doctor bills false visits to gain almost all of the $20,000 available.  The people whose addresses were used are spending time and money to clear their name and credit.  ABC insurance company doubles everyone's premiums to recoup their losses.  One of the men in the car may use Bob Evans's name and ask for a copy of the bill which provides the man with enough information to begin stealing Bob Evans's identity.  The fake Bob Evans opens accounts with department stores, credit cards and goes on a spending spree.  The action of the doctor willingly able to commit to fraud affects those honest doctors.  Their claims will now be in question. 

I was contacted by a doctor who admitted she was part of a fraud scheme, but this was related to workers compensation.  She lost her medical license and just had it returned to her under restrictions.  She paid a fine of $3,000,000.  The court ordered that she could not submit any claims until they were reviewed by a trained and certified medical biller who was approved by the court and who was required to provide reports to the court of the claims. 

We may not be able to prevent the fraud accident. We can take steps to prevent fraud and abuse.

1.  Verify, Verify, Verify the patient and their address.   (I just went to an appointment where someone was using my home address.  The practice never asked for any ID to verify the patient's information, so I was getting his medical bills, his debt collection agency phone calls and law firm letters)  Again, verify, verify, verify the patient, their insurance and their address.  If  a patient becomes indignant or says no, unless there is an emergency, you can ask the person to leave and not accept the person as a patient. 

2.  Submit claims for services that are truly provided. 

3.  All claims submitted must be 100% true, correct, and accurate and verified with the insurance company for benefits, authorizations or precertification. 

4.  Develop and follow your compliance plan as it regards to coding, billing, debt collection, verification of benefits and insurance, patient privacy, patient information protection and fraud prevention.