Insurance is often thought of as a necessary evil. You kind of have to have it, but you hope you never need it. If you don’t have it, you might end up needing it, which would be awful, but if you do have it, you might pay into it for years and years without needing to use it.

When it comes to medical insurance, it’s essential, but when a doctor’s office submits a claim, they need to make sure they do it correctly.

Have you ever thought about what it must be like to be on the insurance guy’s side of the situation? In this story, we find out. One insurance guy shares a story about a claim that had red flags and how his conversation with the lady who submitted the claim only dug her company in a bigger hole.

Keep reading for the whole story.

I don’t have a supervisor lady.

So I’m an insurance guy. I investigate weird claims and work with providers to get them paid. Or to get then to stop committing fraud.

There’s a small number of us doing this, since the vast majority of claims never have problems or can be fixed really easily.

Because of this, the list of people I actually speak to is pretty small, and most people I talk to know me. Like, well enough to ask about my dog and how our party went.

Occasionally though, I talk to someone who has no idea who I am.

He had several reasons to deny one particular claim.

So I’m looking at a claim where the provider missed their submission deadline by 6 weeks. They resubmitted, but with a new procedure date.

This is not a procedure you can have every six weeks. The PA is for a time span including the original date. But those are easy to move and the request had been made.

But since a claim had already been filed, the PA was cancelled all together.

I now have several reasons to deny this claim. I have a note that says the patient’s family has confirmed the original procedure date. I now have a reason to have this provider audited.

He considered this issue pretty urgent.

I call the office. No answer. Leave a message, hang up.

Message is essentially “uh, you guys are in some deep doodoo. Call back now please.”

30 seconds pass and my phone rings.

“Hi this is blank from fraudincfraudfraud’s office, you just called?”

He knows more than he can tell her.

I lay out the details.

“Um. Ok well, obviously there’s been some mis communication here. ”

I explain the information we have from the family. I also have other claims for this patient that I can’t tell her about. But it’s not hard to prove when this was done. I tell her that.

“So I’m going to need a supervisor please?”

I love the Back to the Future reference here!

This is the first time I’ve ever been asked for a supervisor since I started working this job a few years ago.

I’m the end of the line. No one asks me for a supervisor. que Marty McFly voice

“I don’t have a supervisor ma’am. I have a manager, he’s a accountant that knows nothing about claims. But a lot about fraud. If I put him on the phone you will absolutely be audited.”

Dead. Freaking. Silence.

The lady on the phone finally found her voice.

“So… What do I do?”

Thought so. I walked her through the process of canceling submitted claims. I suggested, very strongly, that she cancel any other anomalous claims right the damn now. Going all the way back.

Then I walked to my manager’s office. We talked over the claim history in vivid, excruciating detail, and decided that yeah, they’re totally going to be audited. And all those cancelled flags will make the fraudulent claims super easy to find.

He considers this revenge, kind of.

Nobody asks me for a supervisor.

Ok, so maybe this isn’t so much petty revenge as it is me being petty and doing what I’m supposed to anyway, and getting some sweet justice.

But it sure FELT like petty revenge.

If you enjoyed this story, check out this post about an IT worker who logged on early to fix something simple, and discovered a system-wide cyber attack instead.

Let’s see how Reddit responded to this story.

This person is impressed.

A compliance analyst weighed in.

Another person applauds the story.

One person defends asking for a supervisor in some cases.

He did what he had to do, but there was no way for the lady on the phone to know that asking for a supervisor was a bad idea. She just needed help, but that really backfired. Still, he did the right thing. He saw red flags, denied the claim and saw more red flags when talking to the lady on the phone. This will get straightened out the hard way.

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