Questions on disability insurance, coding, and investigations

Questions on disability insurance, coding, and investigations
By Deborah Green, Esq.

I am suffering from severe back pain, which prevents me from practicing. I filed for disability and my insurer rejected my claim for back pain but said the company would pay if I filed under a mental health disability. Why would my insurance company do that?

Mental health disability benefits frequently are limited to a maximum of 24 months. Once that period expires, you no longer have a claim against your insurer. Insurance companies do this to limit their exposure.

Once you receive notice that your insurer is denying your claim, you should avail yourself of any appeal process offered. The insurance company frequently will offer you several months’ worth of benefits to settle your claim. Think twice before you accept such an offer. Insurance companies know that doctors hate to litigate and often will offer the doctor a settlement that is considerably lower than the amount the claim is worth.

If you do decide to go to court, there is a possibility that you will lose. If you win, however, the insurance company must resume your benefits, pay interest on your past benefits and pay your legal fees. If you live in a state that permits it, you may also file a lawsuit for bad faith by the insurer and may be entitled to punitive damages. Punitive damages may far outweigh the amount of money you are entitled to under your policy.

Consult with an attorney before you decide on any course of action. Do not trust the insurance company’s representations that you will do better if you do not use a lawyer. It is not in the insurance company’s best interest to give you good advice concerning your claim.

I manage a multi-specialty practice, and I am very concerned that all billing be done properly. I have instructed the billing staff to under-bill or not bill at all when there is doubt concerning the proper code. Is this a good idea?

I understand your rationale, but this type of coding, done on a regular basis, could be construed as an inappropriate discount. For instance, assume that a patient is required to pay a 20 percent co-pay. If you bill $80 for a service that should be billed at $100, the patient is required to pay only a $16 co-pay instead of $20. Therefore, this $4 differential may be viewed as a discount, and you may be violating the anti-kickback laws.

Your best bet is to talk to a coding expert and bill for the appropriate amounts. You will get properly reimbursed, and you will not be violating any laws.

I am concerned that some of my employees may be visited at their homes by government investigators who are investigating my practice. Can I order them not to speak to government investigators?

Ordering your employees not to speak with government investigators may be construed as obstruction of justice and will get you into more trouble than you are in now. You can, however, give them some simple advice. Make certain that this advice is not perceived as an order.

You may advise them that:

Image Headshot Deborah Green Deborah Green is admitted to practice law in New York and Florida. If you have any questions concerning legal healthcare issues, please e-mail her at healthattorney@aol.com or fax her at 954-971-3787.

DISCLAIMER: This column is provided for educational purposes only. The accuracy or timeliness of the information presented is not warranted. The information presented is not as legal advice with respect to any matter and that no attorney-client relationship is hereby established.