No, I won't lie to your insurance company (a minor rant)

The BBQ Pit
1

This is my first customer related rant in current job. I’m an insurance biller for a hospital. I make sure the claims are filed properly and paid according to the patient’s policy and/or our contract with the insurance companies.

It is standard procedure in cases of auto accident related claims to file the claim with the at-fault driver’s auto insurance company before filing with the patient’s regular health insurance. Even if there is no med pay available, we have to show proof we attempted to file the claim.

A $6,000 claim came up on my report this past week. In the notes on the account, it was indicated that the parent of the patient (a minor who was at fault) did not want to file with the auto insurance company because it would make the premiums to go up. I can certainly understand this.

One problem: the main insurance is notorious for not paying claims of this nature unless the auto insurance has been billed first. They are well within their rights to do so and it is usually written into the patient’s policy.

When something like this comes up, I send a letter to the insured requesting the information I need and then file the claim for the patient.

Today, right before I’m about to leave, I get into this conversation:

Insured: I got this letter requesting information. I’ve already said I didn’t want to file with my auto insurance because it’ll cause my insurance to go up. I wanted you to file with my health insurance.

MBS: Well, you really don’t have a choice. If I try to file this with the ins co, they’ll see that it was accident related and request the info from you themselves. They won’t pay until they get it.

INS: You don’t have to tell them it was an accident.

MBS: They’ll see the diagnosis codes and figure it out.

INS: Can’t you change the codes?

MBS: No. That would be illegal. (true!)

INS: But, I don’t want to file with my auto insurance.

MBS: Then you’ll have to pay the entire bill.

INS: (moment of silence) Can I get a copy of the itemized bill?

MBS: Sure. Let me verify your address. (which I do). I’ll get a copy in the mail.

INS: Thank you.

My guess is that she’s going to try an end run around us and file the claim directly with the insurance company by altering the bill somehow. This won’t do her any good. The insurance company will contact us for a claim form and when they see that it doesn’t match, they’ll ask for an itemized bill for themselves. If she doesn’t, we will continue to bill for the full amount of the claim.

The insurance company has one helluva contract with us and we’ll be lucky to get 15% of total charges from them and another 2-4% from the insured.

At this point, I could get a copy of the police report in order to get the insurance info, but I have to give the insured a chance to volunteer the information.

I can’t imagine the auto insurance going to go up more than $6K. If it were me, I’d either make the minor pay the difference in the premiums or boot them off the policy and make them get their own insurance.

This idiot might be facing insurance fraud charges because they think they’ll be saving money.

DISLAIMER:
Due to HIPAA regulations, I have rendered the facts in a vague manner.

2

Mr. Blue Sky: Does Georgia consider NOT reporting an accident which involved injuries an offense?

3

I’m not sure. If it’s a car accident, the parties could agree to an out-of-court settlement.

By law, we don’t have to file any insurance claims, but, since we’d like to get paid, we do it as a convenience to the patients.

If that person manages to get the insurance company to pay up, they will pay them and not us. If that happens, the patient is responsible for full amount of the claim. If the patient wants to take advantage of the contracted rates, they’ll let us file the claim.

If they default on the claim because of this and refuse to pay, we can (and will) file it with a collection agency and report it against their credit rating.

4

Or, if you bill the patient’s health insurance as primary payer, they can always subrogate the claim to the auto carrier. Either way, the auto carrier finds out about the accident and the insurance rates go up. Hell, if there was a police report, the auto carrier will still find out about the accident, because they rely on a database that lists accidents/tickets.

Robin

5

My dad recently was on the opposite end of attempted insurance fraud. My dad is retiring soon, and the plan is that my parents will sell their house and move permanently into their beach house. In order to do that, however, they had to enlarge the beach house so that it could serve as a full-time residence. In the overcrowded beach community where the are going to live, that means expanding upwards.

So, the roof came off. During construction, the contractor failed to properly fasten the tarp covering the house, and it blew off in a storm. Everything was soaked through. My dad told the contractor to prepare a list of damaged items for the insurance claim, and send it to the insurance company. Fortunately, he sent my dad a draft.

On the insurance claim were items like bathroom tiles, carpets, etc., that were removed/being removed as part of the renovations. IOW, the contractor was trying to charge the insurance company for items that were either already in the trash or were going to go into the trash.

The motive was obvious - the contractor was going to be liable for anything the insurer didn’t cover, and wanted to reduce that amount as much as possible. My dad called his insurer, told them not to accept the list when they received it from the contractor.

He then fired the contractor’s ass, and we are suing him now (for this and several other fuckups).

Sua