W
hy did they deny my claim? Why am I getting these letters? Did I bill the item wrong?
Am I doing something I shouldn’t be?
All of you have asked at least one if not all
of the above questions, day after day, when you
inspect your mail, EOBs, and ERNs. It seems as
if the more the audits have increased, the higher
the denial rate has climbed. No matter how much
you think you have covered in the documentation
that you have obtained, there is always seems to be
something that gets missed. Sometimes you are over
cautious and look too hard, so you end up missing
things. It’s best to have someone besides yourself
review the paperwork to look for anything you may
have missed.
With Medicare making so many cuts to DME
provider reimbursement, billing a clean claim and
getting paid is imperative. But, as we have all come
to learn, nearly everything Medicare-related has
a mysterious unknown about it; claims and how
to get beyond a denial or review are certainly no
exception. I remember when “there’s an app for
that” was used as reference to almost everything.
Now, with audit reviews and denials out of control
like never before, I sit back, shake my head and say
to myself, “there’s a code for that."
Fortunately, because I have been in this field of
work for as many years as I have, and have worked
with so many providers on many different projects,
most times I know the reason they are denying
these claims without even contacting the carriers.
This is definitely an advantage when it comes to
getting them handled. I am able to rework them in
ways that most people cannot, so that they will get
reviewed or reopened to be reprocessed properly.
So many times, claims get denied incorrectly.
Providers are inexperienced and this is what causes
them to end up dealing with what they are dealing with. They get told something, don’t know any
better, and go with it. This is what ends up hurting
them in the end. I have spoken to so many reps at
Medicare that give me the wrong information on
denials when I call, that I have to request a call
back from a supervisor to make sure that I get the
claim pursued properly. There are times that I have
to actually go above them to a higher supervisor
because I still get nowhere.
I have the know-how to push the claims to the
right areas when they need reprocessing for errors
that have been made by Medicare or the auditor’s
claims processing departments or reviewers. If
there are policies in place that should be followed,
but denial letters indicate that things are missing
or invalid, when in fact each item was sent and is
bang-on based on the policy, then I push until I get
through to someone willing to listen to the problem
and handle it. I am persistent when it comes to
these matters. If you don’t fight for what is yours,
Medicare will keep it. No one and nothing is perfect.
Many times I have educated folks on the other
end of the line regarding certain things because
they are unsure of CMS updates or situations. With
all of the changes Medicare makes day to day, it’s
really no wonder that the system all providers rely
on to handle such a vital part of their business is
such a failure to them. It isn’t our place as consultants, billers, and providers to babysit each and
every claim that leaves a billing system to make
sure that if Medicare does deny it, that they deny it
without error. Be that as it may, these are the realities of Medicare billing in our time.
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Current Pedorthics
November/December 2016
29