Fraudulent Audit Legal Concerns

Summary

Dr. Munroe suspects Patricia Neely of conducting a fraudulent audit, affecting 520 claims and over 130 members for more than a year. Due to HIPAA, Dr. Munroe cannot send notes directly without a legal reason for the audit but can provide them for submission. Despite the audit, Dr. Munroe continues patient care without reimbursement. Concerns arise as the Medicare Payment Policy is used instead of the Blue Cross Blue Shield policy, with no response from Neely and blocked communication. Rachel Wacht has stated BCBS-MA will not provide the policy justifying denials. Legal advice may be necessary to address these issues and ensure compliance with healthcare regulations.

Full Conversation

rephrase "We are informed that Patricia Neely has using this fraudulent audit to deny * claims sent by Dr. Munroe and affect more than * members. It is more than one year. But Dr. Munroe never stop taking care of us even though she knows that she won’t get the reimbusement. We expect BCBS-MA could present your good faith in resolving this issue. "
"Patricia Neely's alleged fraudulent audit has resulted in the denial of * claims submitted by Dr. Munroe, impacting over * members for more than a year. Despite this, Dr. Munroe continues to provide care without reimbursement. We urge BCBS-MA to demonstrate good faith in resolving this issue."
rephrase "We are been informed that your reviewer, Ms. Patricia Neely, is applying the 'Medicare Payment Policy' to deny our claims, accusing Dr. Munroe of billing BCBS-MA for services not rendered. Dr. Munroe has questioned why the Medicare policy is being used instead of the Blue Cross Blue Shield payment policy. Ms. Neely has not answered this question and has even blocked Dr. Munroe’s email instead. Additionally, Rachel Wacht has made it clear that BCBS-MA will not provide the policy being used to justify these denials."
"We have been informed that your reviewer, Ms. Patricia Neely, is using the 'Medicare Payment Policy' to deny our claims, accusing Dr. Munroe of billing BCBS-MA for services not rendered. Dr. Munroe has questioned why the Medicare policy is being used instead of the Blue Cross Blue Shield payment policy. Ms. Neely has not responded and has blocked Dr. Munroe’s email. Additionally, Rachel Wacht has stated that BCBS-MA will not provide the policy justifying these denials."
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