the better chance the patient has for insurance coverage. *******************************
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
I understand why someone would say this but I recall that several LLMD's have been charged with insurance fraud and I really think that miscoding claims to ensure claims payment could very well be the reason.
Anyone know anything about that?
Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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Michelle M
Frequent Contributor (1K+ posts)
Member # 7200
posted
Actually I don't know how a doctor could be faulted for writing any of these things, in addition to "chronic infection" or something generic like that, because in every case at least one or more of them are TRUE.
There is bound to be one or more that fits perfectly -- being both legal and true and also attracting little attention from insurance.
After all, in other diseases the symptoms are treated vs. the cause (chronic fatigue, fibro, etc).
Michelle
Posts: 3193 | From Northern California | Registered: Apr 2005
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
Yes, good point Michelle but the doctor's office has to use ICD codes to submit claims and I don't know for sure but I think a diagnosis code for chronic unknown infection probably does not exist mainly because the insurance company would not want to pay for something that is unspecified or unknown.
I have many diagnoses (is that a word?) - but the insurance company would say that none of them require continous abx or any of the medications for co-infections. In actuallity, that's likely the only thing that will get rid of these things for me.
It seems like everyone, from doctors that were once supportive and aren't now to insurance companies are now hyper vigilent and resistant to a lyme diagnosis thanks to the IDSA BS campaign.
I guess we'll have to leave it up to the good judgement of our LLMD's but this really does concern me.
From what I gather, it is not that hard to get into trouble for insurance fraud. I know of at least 2 doctors who were charged with it and these charges were put on lymenet like they did something wrong when in actuallity they were probably trying to help patients get re-imbursement. Very damaging to the Dr.'s reputation.
Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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randibear
Honored Contributor (10K+ posts)
Member # 11290
posted
hmmmppphhh, one doctor wrote down "psycosomatic" (sorry for spelling)..for me...
one emergency doctor told me to never, ever tell anyone i thought i had lyme or fibro. he said it would open a can of worms that i never would be straightened out.
he was right..........
-------------------- do not look back when the only course is forward Posts: 12262 | From texas | Registered: Mar 2007
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bettyg
Unregistered
posted
question
if you'd like, I'll delete this post! fill me in ... I was relating what I was told thru another source!
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posted
My family has been treated for Lyme and co-infections since 2001. The bills to our insurance company are coded as Lyme disease. There are sometimes other codes such as chronic pain, insomnia, etc.
-------------------- Peggy
~ ~ Hope is a powerful medicine. ~ ~ Posts: 2775 | From MN | Registered: Apr 2001
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minoucat
Frequent Contributor (1K+ posts)
Member # 5175
posted
It really depends on your insurance company, I think. We've had several, and some have given us a huge amount of grief about the "Lyme Disease" diagnosis; some haven't twitched an eyelash.
The term "neuroborreliosis" has served us well instead of Lyme disease. For some reason it doesn't raise red flags.
I think it helps to list the functional aspects of the illness, "has chronic fatigue and is unable to do XYZ", has "fibromyalgia and is unable to do..."
Because we do have these syndromes, most of us, even if LD and Co is at the root of them.
Also, if you write up reports for your doc, as we do before each consult, DON'T write down any exercise you've been getting or any activities that you can do (like shopping for groceries). That's what insurance whacked me for -- I wrote that I'd been doing regular walks with my dog, and some yoga, and insurance saw that when they requested my medical file.
They were short walks, as and when I could do them, and I certainly wasn't doing an hour and a half of Bikram yoga -- but the insurance cut me off pretty much based on that alone; didn't even ask me to clarify it.
You can tell your doc in person about the kinds of things you're doing to get well.
I think it's fair to talk to the doc about your insurance concerns. Some docs just coming into this field are not aware of how quickly insurance companies react to certain phrasing.
Neither you nor the docs have to be dishonest or misleading, but can be sure to include descriptive phrases like "is able to walk dog for short periods once or twice a week, and is extremely tired afterwards" rather than "walks dog regularly".
-------------------- ********************* RECIDITE, PLEBES! Gero rem imperialem! (Stand aside plebians! I am on imperial business.)
TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
minoucat, Are you talking about health insurance denying your claim because you could walk a short ways or are you talking about disability insurance?
I don't think a health insurance company can deny a claim for treatment of a medical condition just because you can walk your dog. On the other hand, disability companies are notorious for this type of denial.
Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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minoucat
Frequent Contributor (1K+ posts)
Member # 5175
posted
yep, that's what happened. I got a nastygram from the insurance, focusing on the fact that I said I walked my dog regularly and was doing other things like yoga. Well, I like to tell my doc the good news -- I just shouldn't have put it on paper.
The other problem the insurance mentioned in passing was that I was taking a break from abx at the time and was doing the Cowden protocol. However, they didn't give me heartache while I was doing the Buhner stuff, so I have to think the dog walk clinched my fate.
Insurance didn't ask for an IME or anything. Just sent the letter canceling my coverage immediately. I could have challenged but didn't -- was feeling too anxious and depressed, and I didn't think it would work, anyway. It turns out I was having a bartonella relapse, so now -- ironically enough -- I'm back on abx.
Ain't life a kick.
-------------------- ********************* RECIDITE, PLEBES! Gero rem imperialem! (Stand aside plebians! I am on imperial business.)
TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
minoucat, hmmm... makes no sense to me. I guess you are saying this is your health insurance company and not your disability company???
An IME (Independent Medical Exam) is usually used for disability claims.
Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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Aniek
Frequent Contributor (1K+ posts)
Member # 5374
posted
minoucat,
I am assuming this is disability insurance or medical insurance that you received due to being disabled.
I'm sorry for what happened, but a large numbers of cancellations of disability insurance are reversed on appeal. They do these cancellations just because they know some people won't bother appealing.
As for medical diagnostic codes, the diagnosis code needs to match with the procedure code. So if the doctors puts down fibromyalgia for antibiotics therapy, the antibiotic therapy will not be covered. There needs to be an infection code for antibiotics to be covered.
Many doctors will put down multiple codes to deal with this. For example, my doctor puts down codes to fit the symptoms as well as the diagnosis.
-------------------- "When there is pain, there are no words." - Toni Morrison Posts: 4711 | From Washington, DC | Registered: Mar 2004
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minoucat
Frequent Contributor (1K+ posts)
Member # 5175
posted
Functionally, for me, the disability insurance WAS the medical insurance. So when disability canceled me, I lost my medical insurance--unless I could pay their astronomical fees as a private person, which I couldn't. This is the case for most people.
However, the hubby's medical insurance functioned in a similar way. They blocked payments for his meds because they didn't believe in the Lyme diagnosis, and they didn't see how he could be so sick from a non-existant disease. Mind you, he was deep into "pre-approved" treatment at the time, so we were suddenly facing a huge bill. Our doctor at the time was not skilled in using dx codes effectively. We fought that one and won.
The point here is that what you put in your written record can be used against you by both your medical and disability insurance.
I agree that you need to have an infection code for abx, but as you say, Aniek, it does help if the doc knows to mark all your dx and sx codes down, so that you look on paper as sick as you are in real life. And to have a self-created record on file about your sx, functional, objective, and subjective.
Not all insurance companies have been this hardassed -- in one case, we only started having problems when our original insurance co was bought out.
I've fought denials, and won, at least 5 times for the hubby and me. I know it can be done, but I also know how much work it takes. This last time I just wasn't up to it.
I was able to buy medical insurance that has a HUGE deductable for tests and consults, but a very small one for prescription meds. It has a fairly low premium (so far). My state has a requirement about availability of affordable insurance in certain circumstances, thank heavens.
-------------------- ********************* RECIDITE, PLEBES! Gero rem imperialem! (Stand aside plebians! I am on imperial business.)
posted
boy, this has brought lots of discussion of pros and cons of things!
I feel for all of you fighting the denials! I know it took me 18 months of hell and copying at least 300-450 sheets to fight them, and they used ONE SHEET AGAINST ME!
she knew when she signed this opted out of medicare form that there was a good chance she would NOT be reimbursed!
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quote:Originally posted by bettyg: .....she knew when she signed this opted out of medicare form that there was a good chance she would NOT be reimbursed!
Clarification please, she who?
I think I understand Bettyg's source of info.... but in our case the lyme dx for orals didn't raise any flags, however the IV treatment for lyme is limited to 28 days in our policy and seems to have caused problems. Now the lyme iv limit is met it seems everything iv is denied!
I am fighting the denial of FLUIDS- not for lyme, but ins co says they are! Actually they paid the claim for inpatient and outpatient iv fluids at hospital, but not for us to do them at home! Go figure!
Next thing on horizon is probably TPN. Since it will require hospital stay it should not be problem, but I hate to try and keep up IV abx in hospital... sounds like a nightmare to me!
IV abx for bartonella was denied saying it is lyme! I have a copy of paper where case manager wrote through bartonella code and wrote lyme!
It seems that now the lyme dx is there everything iv is denied. But wait, didn't the 28 days cure it!
Someone posted here that they got longer iv treatments paid for by coding "bacterial infection of unknown origin". Response to abx warranted continuation. Now I wonder if our "test" was negative if we can claim this! lol
So yes lyme puts up flag. Ironic, I have a positive test. But not by CDC! I had ID duck say before running tests "I will be able to tell you what you don't have (including lyme), but I might not be able to tell you what you do have". Too bad he said fibro! "bacterial infection of unknown origin" might help.
MommaK
Posts: 242 | From Mississippi | Registered: Oct 2006
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bettyg
Unregistered
posted
quote:Originally posted by MommaK: [ ]Originally posted by bettyg:
.....she knew when she signed this opted out of medicare form that there was a good chance she would NOT be reimbursed! [/qb]
Clarification please, she who?
I think I understand Bettyg's source of info.... [/QUOTE]
Betty's clarification;
BCBS stated that since I signed the OPTED OUT OF MEDICARE FORM MY LL MD requested I do BEFORE she would see/treat me, that the LLMD form stated in small print that "you may not be reimbursed by secondary insurance co."
so after 18 months, it was that sheet of paper i included that they used against me to DENY BCBS FROM REIMBURSING ME towards the $4,000 of lyme appts/expenses!
BTW, they had that sheet of paper from day 1 when i started sending in ALL my expenses as they occurred.
they refused to deal with this for 18 months; i had iowa insurannce commissioner's office attorney involved for 9 months before i got this response!
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
quote: *****If the doctors can have their licenses removed for treating you for lyme, then they can "legaly" not write in the diagnose of lyme but the coinfecctions and symptoms and treat you based on them.****
I could be wrong but it seems that a ruse is often used to take action against our LLMD's. Technically other charges besides treating lyme are used in the legal documents.
If you are given a diagosis of one of the co-infections I think you will be in a similar position of needing positive tests in order to justify treatment. That's OK for some people but many of us are diagnosed clinically. Perhaps the Fry lab blood smears would suffice but I don't know if they would fight that too.
The RA is a good tact and might work. There are probably other things along those lines that could be done I would think.
Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
BettyG, I'm sorry for the horrific experience that you had with the insurance situation.
For anyone with the typical medigap policy - they will only pick up expenses that are covered expenses under medicare - period. Your doctor is an uncovered expense under medicare if they have opted out. My doctor has opted out of medicare and my BCBS medigap does not cover a penny towards my LLMD costs. It may be different for those people who were Federal or State employees.
I was told by medicare that if your opted out doctor still has a medicare number (I'm not sure under what circumstances this would occur) that some of the tests that you have done through the opted out doctor can be covered. In that case, your medigap policy would pay a percentage of the tests if any of it wasn't covered by medicare.
Betty, I wish yours had been covered but it is good to bring it up so that others can make sure they know what is covered before they see a new LLMD because it can be tricky.
Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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heiwalove
Frequent Contributor (1K+ posts)
Member # 6467
posted
my LLMD's 'official' code for my dx is chronic fatigue syndrome. of course we both know we're dealing with lyme & babs, etc, and i don't have insurance so am unsure how things would work out if i did -- but i'm pretty sure insurance reasons are why i (and perhaps other patients) are coded as having something other than lyme.
TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
Cave wrote: It depends on the 'plan' (again!!)
I guess I should have been more clear. My understanding (and what I have been told by medicare) is IF you have the standard medigap policy that is regulated by federal law - they will not reimburse you for expenses incurred by a doctor who has opted out of medicare except in the case that I mention above relating to tests.
It seems there are always exceptions (like with State or Federal employees) so it's good to double check but ultimately, the standard medigap policy is governed by federal law and regardless of which company you buy from, the policies are identical in coverage, exclusions etc..
That said, this was the case 2 years ago when I was checking on coverage for my LLMD and things could have changed but I haven't heard of any changes.
Keep in mind that I'm talking about the standard Medicare and medigap coverage. There are other plans that have evolved over the past few years that are HMO and PPO in which case coverage can be limited to network doctors.
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