BCBS did a "review" of pain management practice and also encouraged me to submit a formal complaint
My doctor's office failed to accurately complete PAs for my medication for nearly six months. BCBS instructed me to file a grievance in order to get a retroactive PA for reimbursement. It became clear that numerous pts have been affected by the office's incompetence re PAs. I am certain that BCBS initiated a "review" as a result. What exactly would such a "review" entail?
Because of these issues, BCBS also encouraged me to file a formal complaint. There are numerous issues beyond the PA fiasco with this practice—numerous HIPAA violations, employee's entry of false statements in my records to cover up an error they made, another employee lied to me on one occasion to cover up a coworker's error, sending wrong prescriptions to pharmacy and failing to return phone calls–had to resolve in person, MRI went unordered for three weeks and staff failed to return any phone calls–also had to resolve in person, demanding payment of co-pays I did not owe in order to see provider (had met OOP max), took a full year to receive my full records despite submitting four requests, two highly incompetent NPs (one had never heard of a common NSAID–at a PM practice!), audit trail shows employees improperly accessing my records, and most importantly, entering false information in my records regarding exams completed. There are also numerous errors in my records.
Would the issues above be of interest to BCBS? I also discovered in my records that this practice has listed results of a physical exam that was never completed. In each visit's office record they have copied and pasted the results from a singular physical exam completed two years ago. So not only is the information incorrect–it includes fictional findings–the fact that they have copied and pasted this single exam in each visit makes it look like they actually completed an exam at that visit, when, in fact, they did not.
After examining my billing records, I am wondering if this fictional exam has been included in order to upcode each office visit.
My final question (thanks for reading this far): I will file a formal complaint that addresses the possible upcoding, failure to submit Information requested for PAs for months, and possibly the issues listed above. I realize that BCBS will not share any info with me regarding a potential investigation. I'm just curious: what typically happens when a complaint such as mine is filed? How would this differ from the "review" a BCBS employee told me was occurring as a result of the PA issues? What possible actions would BCBS take as a result of the complaint/investigation?
Many thanks for reading and sharing your expertise!
submitted by /u/Puzzled_Swim_8681
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