Posts Tagged ‘denials’

In this month’s Southern California Physician magazine AAPC member Hidy Borden LPN, CPC, CPC-I discusses how to overturn reimbursement denials or avoid them in the first place. This article is not available online, but can be found on page 10 of the February issue.

Independent clinical/pathology laboratories and in-house laboratory services performed by medical practices are under one Medicare Administrative Contractor’s looking glass. Palmetto GBA recently published an article that identifies problematic ordering trends noted during a review process.

The Palmetto review staff examined records for several claims related to laboratory errors for which denials for testing procedures were generated to better address problems identified during reviews conducted by the comprehensive error rate testing (CERT) contractor.

For every claim selected for review, Palmetto found “recurring, widespread problems with various aspects of the ‘ordering’ process,” and the reason procedures were deemed medically unnecessary by CERT and denied.

Problematic ordering trends, Palmetto says, include:

• Absence of any type of requisition, order or valid documentation of “intent” by the ordering-treating physicians or qualified non-physician practioners (NPPs);
• Preprinted test requisition forms did not include signature/initials of the ordering/treating physicians or qualified NPPs;
• Preprinted laboratory requisitions or orders were complete and signed/initialed only by auxiliary staff, not the ordering physician or qualified NPP; and
• For lab service performed and submitted by practices in-house, the patients’ medical charts or progress notes were somewhat illegible, did not list or even mention the test or blood draws, and/or did not meet Medicare’s signature requirements.

Palmetto found when the ordering/treating practitioner’s staffs are contacted directly by CERT, the offices fail to respond to direct requests for corroborating documentation, orders, medical chart notes, etc. When information is supplied, the patients’ records are often unacceptable because the records are unsigned and/or omit any reference to the tests being ordered.

Palmetto reminds practitioners that if they do not reply to CERT follow-up requests, or send insufficient/invalid records, Medicare will hold the billing laboratory financially responsible for any incorrect payments.

Want to increase the number of claims that successfully complete processing and enhance a positive cash flow? Heed Noridian Administrative Services’ (NAS) advice. The Medicare administrative contractor (B/MAC) has identified its top five denials for the months of July, August, and September and offers solutions and resources. Read more »

Wondering what you should do if you receive a claim denial due to untimely filing that you believe to be unjust? Request a reconsideration. UnitedHealthcare offers advice on what you should submit as evidence of timely filing.

For electronic claims, include confirmation that UnitedHealthcare or an affiliate received and accepted your claim. Effective Dec. 1, proof of timely filing from an electronic claim submission must include confirmation that UnitedHealthcare accepted the claim. The submission report will no longer be accepted as proof of timely filing.

For paper claims, include a copy of a screen print from your accounting software to show the submission date. The information must show that the claim is for the correct patient and visit. Also include other pertinent information, such as an insurance carrier denial/rejection, explanation of benefits (EOB), a letter indicating terminated coverage, etc.