Doctors Issued Fraudulent Medicare Cards By Insurance Companies
Most physicians are quite familiar with the following scenario. The insurance company advises the physician that he or she will be paid according to a certain fee schedule. Time passes, the physician examines the amounts reimbursed for services rendered and it is evident that the amounts paid are far less than what was agreed. The physician complains and the insurance company advises the physician that the fee schedule was modified and that the physician was notified about the modification before it was implemented and, in fact, had agreed to the modification. On further inquiry the insurance company explains that it faxed a “notice” to the physician informing the physician of the change and that unless the doctor opted out within a certain period of time (usually 30 days) the doctor is deemed to have accepted the revision. The insurance companies have used this notification methodology for years because they understand that most physicians are simply too busy to review every piece of paper that comes to them by fax or mail and that by the time the physician finds the “notice” (that is assuming the physician even received it), the physician is deemed as having accepted the modification. Such “notices” have been used to revise many important components of the provider-payor relationship.
Now the insurance companies are using this methodology coupled with potentially fraudulent practices to force physicians who never agreed to treat Medicaid patients to accept Medicaid patients at Medicaid rates. First, the insurance companies send the physicians the “notices” advising them that, unless they opt out within 30 days, they will be deemed as having accepted treating the insurance companies’ Medicaid insured at the Medicaid rates. The physicians never see the notices so they are deemed as having accepted the obligation. Second, when the Medicaid patients show up at the physicians’ offices, they present health coverage cards that identify them, not as Medicaid patients, but rather as commercial HMO patients (which has a higher reimbursement rate). The physicians render the services not realizing that they are treating Medicaid patients at Medicaid rates. It’s only when the physicians are reimbursed (assuming they are even reimbursed) that they realize what has happened. But by then it’s too late!
If you are a physician and find yourself encountering this situation, please contact us at mdpcelaw.com or (914) 517-5000.