MEDICARE CODING ISSUES
National Correct Coding Initiative (NCCI) and Multiple Procedure Payment Reduction (MPPR), failure to pay due to utilization limitations
- If the insurer states they did not pay a code or reduced a code for the above reasons, call us or send us your EOBS/files.
- This coding information is found on the Explanation of Benefits.
- Some insurers are denying payment even if a practice sends an Emergency Medical Condition Report. They deny utilizing a Peer review which is NOT PERMITTED.
- Insurers hire humans to work for them. It is human nature to assume you have not received documents or to omit a document in your file. If an EMC was sent with the claim and the insurer requests the same again, a suit may be immediately filed!
PROOF OF MAILING
- Claims have been sent but the insurer alleges they did not receive a particular date of service. If the insurer re-requests the bills, you do not have to do double work. The insurer’s delinquence is actionable.
- If we litigate on behalf of the practice, you will receive interest payments plus the money you’re owed. To prove the claim was mailed in a timely fashion, always keep a copy (re-printed is ok) of the actual HICFA and an envelope or tracking number proving the bills were initially mailed.
PATIENT GIVES INCORRECT INSURANCE INFORMATION AND YOU RE-SUBMIT THE BILLS AFTER DETERMINING THE CORRECT INSURANCE CARRIER
- Do not fret if this situation occurs. Providers have a full 35 days to send claims to the correct carrier.
- Example: Patient A State Farm is their PIP insurer. Practice sends claims to State Farm. State Farm responds stating Patient A is not covered by State Farm and in fact, is insured by Progressive.
- You now have 35 days from the date you received the correct information to re-submit the bills. Include a copy of the means in which the correct information was received as proof of the date received.
*HELPFUL NOTE: USAA alleges you have 15 days from the date you received the correct information. That is untrue. Do not be tricked into the insurer’s manufactured timetables.
FEE SCHEDULE LITIGATION
- Some insurers’ policies do not elect the fee schedule in a clear and unambiguous manner. In light of recent District Court of Appeals decisions, insurers must make both the insured and medical provider aware of the reimbursement choice; whether they pay 80% of the charges OR per the Medicare Fee Schedule.
- It is our goal at LaBovick Law Group to fight the good fight and ensure maximum reimbursement.
- State Farm’s pre-2012 policy, Allstate’s pre-2012 policy, MGA’s policies, and a slew of other insurers’ policies should be litigated because they are not compliant in the manner in which they reimburse for provider services!!!!!!!!