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I am a a nutritionist and provider of Harvard Pilgrim.

I am a a...

I am a a nutritionist and provider of Harvard Pilgrim. Harvard Pilgrim, a major health insurance company is looking for a retraction of payment given to me from 2014 onward to 2017. They claim I did not get a Physician Order (which is different from a referral). I have interviewed 20 nutritionists and no one has ever followed through getting a physician's order. Can I get out of this by claiming that they never told me there was a problem or anyone else that I know who is a provider with them.

Lawyer's Assistant: What state are you in? It matters because laws vary by location.

Massachusetts

Lawyer's Assistant: What steps have you taken so far?

I hired a lawyer. In the letter sent by Harvard Pilgrim, it clearly stated that they wanted a Physician's order. He told me that the Physician's order was the same as a referral. So he provided my evidence that I always followed the rules for getting referrals. HP response to my letter was they want Physician's Orders not referrals. I spent $3500 with him so far and he did not listen to me. I am discouraged with the process moving forward with him.

Lawyer's Assistant: Anything else you want the lawyer to know before I connect you?

I would like to know I can use "implied consent" in this case.

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Customer reply replied 26 days ago
Did you get the audit policy?
Answered in 10 minutes by:
3/28/2018
Law Educator, Esq.
Category: Legal
Satisfied Customers: 123,264
Experience: JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
Verified

Thank you for your question. I look forward to working with you to provide you the information you are seeking for educational purposes only.

In order for HP to pay claims they require proper documentation. Implied consent is not the same as receiving doctor's orders. A doctor's referral is not the same as a doctor's order. A doctor's order is along the lines of a prescription saying the patient requires a nutritionist, not a referral only saying go see so and so for nutrition support and counseling (which I do presume they tried to explain to you).

You will need to go back to the physicians and seek to get them to update the orders for you. Most physician offices will do so for you. You cannot argue that none of the other nutritionists are doing it, but if you read your HP provider agreement, you can see in there whether or not it says you are mandated to get orders and if it does not, then you can sue HP for breach of contract. Unfortunately, if it says in the contract orders are required, you have to go back to the doctors of those patients to get a doctor's order to get the claim paid and not refunded.

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Customer reply replied 26 days ago
Thanks for you reply.
I understand the prescription order would be in the physician's notes. This is a difficult situation.. to ask them to put it in a note. It would be a current note not a past note, is that right? A present note to see a nutritionist would be acceptable in my case??
I tried to send you the attachment for the audit policy but I don't think you received it.I tried to send you the audit policy as an attachment. Did you receive it?

Thank you for your reply.

The doctor can retroactively correct the records, so yes, the doctor may amend the patient's record if they choose to do so under HIPAA and it would be permissible. They can state they are amending the patient's chart for the date they sent the patient to see you, again that is the doctor's discretion and choice.

I did see the audit policy, did you have specific questions about that?

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Customer reply replied 26 days ago
Thanks for your answer. okay, they can amend it. Good to know! There is nothing specific in the the terms of retraction concerning the Physician's Order, Right?

Thank you for your reply.

In the audit policy there is nothing specific, but as part of their audit if they find no doctor's orders, could violate your provider agreement and if it does, then I am afraid they would have you for breaching the contract.

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Customer reply replied 26 days ago
okay, it is hard hearing the Truth. I am being targeted.
Does MA have a limitation date for retractions?

Thank you for your reply.

The terms of your contract would dictate the retraction period and the audit period says 225 days beyond the 36 month period (roughly) under contract is the time they have to retract. However, for breach of contract under MA law, which is what the retraction is under, it would be a 6 year limitation period.

If you are being targeted and can prove it is not in your contract regarding the orders, then you need to sue for them breaching their contract.

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Customer reply replied 26 days ago
Thanks. I am trapped.

Thank you for your reply.

Sorry to hear that.

Please do not forget to leave positive feedback by clicking on the 5 stars at the top of your page, as the experts are not employees of the site and get no credit for spending time with customers unless they leave positive feedback. Thank you.

Law Educator, Esq.
Category: Legal
Satisfied Customers: 123,264
Experience: JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
Verified
Law Educator, Esq. and 87 other Legal Specialists are ready to help you
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Customer reply replied 26 days ago
Sending you the Audit policy..

Thank you for your reply. I got the initial audit policy you sent, did you have specific questions about it?

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