REDEFINING DIAGNOSIS "CODES" ELIMINATES CONDITIONAL PAYMENTS CLAIM

June 2017

Following a claim settlement in which all known medical treatment bills had been paid by the insurer, Medicare submitted a claim for reimbursement of conditional payments in excess of $17,500.00. According to the representative of CMS, the charges were all related to the claim, because the records of the medical providers included the same diagnostic codes as those used in the treatment of the underlying injury.

In our initial assessment, we noted the majority of bills in the CMS claim were submitted by medical care providers that were not involved in the claim prior to the settlement. We recommended further investigation, and the claims handler authorized medical records subpoenas. The records that were obtained demonstrated that the coding had nothing to do with the actual treatment. The body parts and conditions listed in the records, and the actual treatment and services that were rendered by these providers had nothing to do with the claimed injuries.

Despite the repetition of coding the bills sent to CMS, none of the charges were compensable as part of the injury claim. Our team submitted to CMS a detailed argument, along with copies of the pertinent records. CMS responded by removing all charges and closing its file without collecting any reimbursement.