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I believe my doctor knowingly submitted inaccurate medical coding/claims to my insurance company in order to get more money.

Salt Lake City, UT |

I was seeing a jaw speacialist (maxillofacial doctor) to treat TMJ (clenching of the jaws). I was without a doubt diagnosed with TMJ and referred to a specific phys. therapy doctor for additional treatment 3 x's a week. lots of laying in a room, heat pads and occasional facial pulse therapy. That was it. I was on my mom's insurance at the time. Two years later I go to get individual insurance and am quoted an outrageous amount due to being treated for FIBROMYALGIA. Find out that my phys. therapist was filing claims to Blue Cross stating that he diagnosed me with fibromyalgia. Nope. Don't have it. Also learned that my insurance didnt cover TMJ, so we think he was coding it so insurance would accept it and get more money. I was subsequently denied insurance after everything. More details.

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Attorney answers 3


Call him to discuss or report him.

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You're entitled to a straight explanation from the doctor and/or therapist. Insurance fraud is a serious matter and the licensing authorities take a dim view of it.


Your best bet is to talk to the doctor’s office ASAP and try to get to the bottom of it. You also need to get a copy of your medical records and see what they discuss in terms of treatment and/or diagnosis.

Good luck.

DISCLAIMER: David J. McCormick is licensed to practice law in the State of Wisconsin and this answer is being provided for informational purposes only because the laws of your jurisdiction may differ. This answer based on general legal principles and is not intended for the purpose of providing specific legal advice or opinions. Under no circumstances does this answer constitute the establishment of an attorney-client relationship.

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