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Don't Sign It If You Didn't Do It
Blue Cross Blue Shield of Montana (BCBSMT) has recently identified a number of problems with claims billed by providers who did not actually render the services provided to the patient. These problems include billing for services provided by non-licensed personnel and billing for services provided by providers of another specialty.

BCBSMT member contracts are designed to provide benefits for necessary covered medical expenses if they are rendered by a covered provider. In order to be covered, a provider must be licensed by the State of Montana and recognized by BCBSMT as a provider of services. Services must be rendered by the provider who is listed on the claim.

Some of the problems we’ve identified are detailed in the following examples:
  • Billing for services performed by another provider of the same specialty in the same clinic. Several cases have identified providers of the same specialty working in the same clinic, but all claims billed by the clinic are billed under one provider’s name, regardless of who provided the actual service. This is incorrect – claims should ALWAYS be billed under the name of the provider who actually rendered the service.
  • Billing for services performed by a provider who does not participate with BCBSMT under the name of a Participating BCBSMT provider. Again, claims should ALWAYS be billed under the name of the provider who actually rendered the service.
  • Billing for services performed by a Mid-Level Practitioner (Physician Assistance or Nurse Practitioner) under the name of an MD or DO. BCBSMT reimburses mid-level practitioners at an allowance determined to be appropriate for their licensure. Claims should ALWAYS be billed under the name of the provider who actually rendered the service.
  • Billing for services performed by a Massage Therapist under the name of another provider. BCBSMT does not recognize Massage Therapists as covered providers. Although a number of Chiropractors, Physical Therapists, and MD’s employ or work with a massage therapist in some capacity, any services actually provided by the massage therapist MUST be billed under their name. One more time, claims should ALWAYS be billed under the name of the provider who actually rendered the service.

To bill for services you did not perform is incorrect. To intentionally bill for services in your name that you did not perform to obtain benefits that otherwise would not have been available is fraud! Montana Code 33-1-1205 requires BCBSMT to report suspected fraudulent activity to the State of Montana Insurance Investigations Bureau for investigation by law enforcement authorities. If you have questions about how to bill, contact the BCBSMT Healthcare Services Department or the Special Investigations Unit.


Bill for What You Did, Not What the Insurance Will Pay
A common issue we deal with in the Special Investigations Unit is claims that are incorrectly billed for the purpose of obtaining the maximum payment from the insurance coverage. These claims often misrepresent the condition being treated or the service that was actually provided.

Generally, BCBSMT contracts cover the majority of services that a patient will receive. There are, however, exclusions and limitations designed to help control the cost of premiums on the contract. In many cases, group employers pick and choose from a variety of benefits to tailor a benefit package that is affordable, yet comprehensive in coverage. Unfortunately – some providers choose to manipulate claim information, such as diagnosis codes, procedure codes, dates, etc, in order to maximize the insurance payment. There are typically three reasons for misrepresenting claim information.
  1. Obtain benefits that would not otherwise have been available – This is typically done by billing covered codes in place of non-covered codes or by upcoding the services actually provided to make them worth more.
  2. Ease of collection – Many providers misrepresent information to obtain additional benefits from the insurance, as this increases the ease of collecting the balances due from the patient – especially if the insurance check goes directly to the provider.
  3. Reduction of the patient’s out-of-pocket contribution - While the patient may realize an out-of-pocket savings at the time, this type of activity will contribute to increased premiums in the long-run – negating the short-term savings. If premiums increase too much, it could even result in the reduction of benefits (to offset the resulting increase in insurance costs), the total loss of health insurance, or a potential reduction in the patient’s salary (on a group health insurance contract).

The manipulation of claim information to obtain additional benefits is a classic example of insurance fraud (see the Identifying Fraud page on this web-site). BCBSMT is concerned about this type of activity and actively investigates any complaints of this type. All cases that are confirmed fraudulent are referred to the Montana Insurance Investigations Bureau for law enforcement follow-up, as required by Montana Code 33-1-1205.
Three Words that Work
Documentation - Make sure your medical records are as complete and legible as possible.

Documentation - Document any training received by yourself or your staff, including the names of the people who presented the information.  Keep copies of the reference material provided, if applicable.

Documentation - Keep copies of any other materials used as references in billing claims.  These may be critical if you are accused of billing incorrectly.

Note: The Third Quarter 2003 Capsule News includes a detailed article on medical records documentation.
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