SIU Procedures

[unsurepat]

Virginia

Hello guys,

I had been outside the country (to my home country) and became sick during that time. I was admitted and charged a bill by the doctor. I did pay all the money and asked my insurance agency whether I could file a claim or not. They said I could definitely submit one. I went ahead and they mailed me the money which I had deposited. About a month or so later somebody from the SIU sent me a letter saying that they are reviiewing charges against me (because they feel that the charges are high - I have just sent whatever the doctor has billed me). They had asked for an explanation of benefits form which I filled out and sent to them. They came back to me asking for day-to-day reports and doctor details and I have diligently sent everything over. Still they wanted to investigate further and they have actually carried out investigations in my home country.

The investigation into the claim is still ongoing. Now my question is - I am not sure what the outcome of the investigation report will be. If they do determine that the charges are higher than what they are supposed to be (according to them) - how will the process go from there? I am very scared because I have never been involved in any kind of investigation before and I have nightmares about my insurance company deciding that this is some kind of a fraud (which this is not!!!) and just sending cops to my home.

[ecmst12]

If you have not actually committed any fraud, you should have no worries about police. I don't know if they are investigating you or the doctor/hospital that treated you - do you?

[unsurepat]

I do not know exactly what are they investigating. When I am calling the agent up and asking about the case - the most I can get is - the investigation is being carried out. Not sure whether I can ask them direct questions about procedures/next steps?

[ecmst12]

You can, and should, ask as many questions as you like. Just be aware that in light of an ongoing fraud investigation, the information that they can give you is probably minimal.

[jwmc1701]

It's standard operating procedure to investigate foreign claims, especially from certain countries and especially larger dollar claims. They'll verify that the services claimed were actually performed and that they meet the terms of coverage of the contract. They'll also verify that you paid for all the services.

Beyond that, they will subject the charges to review of reasonable and customary per the terms of your contract.

It doesn't mean you've done anything wrong. It could be the doctors or facilities you went to. If you know you personally didn't do anything fraudulent you have nothing to worry about.