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Changing Procedures Done

Is it legal for a medical insurance company to change the types of procedures a providers does and submits when they pay the claim? In other words can an insurance company legally change 7 lab tests to 7 unspecified medical visits when paying the provider. By doing this they paid the provider more than would have been paid under the actual work done, resulting in higher copays.
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282113 tn?1388159749
Dear jb111o,

I cannot speak to legality of your question but it seems like your provider may have not used correct codes to submit their claim. Your insurer pays claims based on what your provider submits to them.

I recommend you check with your provider to make sure your provider is submitting accurate codes for services rendered. If that is not the issue, then you should contact your insurer for explanation.

I hope you find this information helpful.


Amir Mostafaie
Helpful - 1
Avatar universal
The providers are overseas providers who submit claims for US citizens. Under their contract they do not submit codes but the procedure description and the insurer adds the codes and then determines if the billed amount exceeds the maximum allowable.

In this case the 7 lab tests were clearly identified on the receipt to the patient who paid a copay. Simple tests such as urinalysis, CBC, Creatinine etc. In addition the insurer denied a claim as a duplicate for the same day at the same amount which listed the 7 lab tests yet paid the second for the same day and the same amount using 99499. If the provider has submitted a second claim for 7 unspecified visits how did the insurer know that it was a duplicate of the one that listed 7 lab tests? We think they are in collusion to defraud since, if they had used the 7 lab tests a significant amount would have been disallowed as over the maximum allowed. Instead they paid 100% using 99499.
Helpful - 0
Avatar universal
Doesn't appear there are to many health insurance experts here.
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