Is this Insurance Fraud?

[jilly]

State: NC
Ex is CP and we have joint legal

I am not court ordered to carry medical insurance on DD or pay a portion of or all of any medical expenses.  Ex was losing her job/insurance early last year and asked me to carry DD on my insurance, to which I agreed.  I have willingly paid co-pays for doctor visits, as needed.

DD had several therapy sessions last year.  In the beginning she was seeing an M.D. but Ex changed to an LCP within the same practice.  The LCP is not supervised by an M.D. and my insurance will not cover charges for an LCP if they are not supervised by an M.D.  There was some back and forth on this matter between me and Ex until I provided her with copies of e-mails from the provider stating the above.  She quit taking DD to therapy sessions and nothing more was said about it.

I recently was reviewing EOBs for my DD and noticed that a charge for a therapy session was resubmitted on 01/19.  My insurance didn't pay for this as payment had been made previously and it was noted as a duplicate claim.

I contacted my insurance carrier and questioned this. Turns out that the 3 visits with the LCP have been resubmitted.  Only this time they are showing the provider as being the M.D. and not the LCP.  I informed the representative that this was not true and that DD did not see the M.D. on those dates of service.  I asked the rep if it was acceptable to submit bills like this and she said it most certainly isn't.  When I asked what they were going to do about it she said "Nothing.  If she has more visits and the bill is from the M.D. we will request a copy of the records."
 
I'm thinking that the Ex told the therapist's office that the only way they'll get payment for those visits is if the services were provided by an M.D. so the therapist's office has resubmitted the bills.

1.  Would this be considered insurance fraud?

2.  If so, how would an action be started?

3.  Is it up to the insurance carrier to file for this, especially since they've been put on notice what the therapist's office did?

Thanks for your help!

[socrateaser]

>1.  Would this be considered insurance fraud?

Probably, but if the insurer doesn't care, the DA won't either.

>2.  If so, how would an action be started?

Forget about it. The alternative is that you'll be paying one half of the unreimbersed LCP charges.

>3.  Is it up to the insurance carrier to file for this,
>especially since they've been put on notice what the
>therapist's office did?

Not necessarily, but without the carrier as a witness, the DA won't be interested. Also, we're talking about next to no money here, so the DA won't expend taxpayer resources to put a 12 person jury together to hear a case where there's only a couple hundred dollars at stake.

You need to determine why this is bothering you, because it seems as though you're looking to manufacture a punishment for your ex. Revenge never gets you what you want in life, unless you're already a criminal type.

[jilly]

Thanks Soc!