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Insurance Payments / Re: recoupment request for Out of Network
« Last post by PMRNC on Today at 04:26:39 PM »
If any of these recoupment requests are on ERISA group health plans, there most certainly is a remedy. With ERISA a carrier (regardless of the reason for requesting recoupment) MUST recoup from the patient NOT the provider. Again, if it's ERISA, it is a patient's claim, not the providers claim.

Most billers still don't understand that almost 90% of the claims they file are ERISA!
Insurance Payments / Re: recoupment request for Out of Network
« Last post by Michele on Today at 02:27:17 PM »
We often receive recoupment requests for providers (in Central NY area) a year or more later.  Very frustrating as it is always too late to go after another insurance (if that is the issue) or the patient.  I know you can legally bill the patient still (if the issue was not something that was the provider's fault) but the chances of collecting old debt are so much lower.  Unfortunately I do not know of any way to stop this.  Most times they say they performed an internal audit.  :(
Billing / Re: United Health Care WOL
« Last post by Michele on Today at 02:24:54 PM »
I have not heard of that.  Personally since you are not participating I would think it's up to the patient to appeal.

Coding / Re: Orthopedic coding
« Last post by Michele on Today at 02:22:26 PM »
The documentation I have indicates that the 29805 and 29821 are included in with the 29823. 
Insurance Payments / recoupment request for Out of Network
« Last post by EZlabor on Today at 11:49:21 AM »

 Blue shield of CA and Blue Cross of TX appear to constantly pay OON claims and then request a recoupment for "overpayment" almost a year later. What, if anything, can be done to stop this. It seems they randomly pick claims. The reason is they overpaid, oops, sorry and we want that money back now. I tried looking up the rules for CA providers? and I am not clear on providers rights to contest this constant harassment.
Does anyone have experience with this issue? Or know the provider rights with this issue?
Billing / United Health Care WOL
« Last post by PMBS on September 20, 2018, 09:57:33 AM »
I recently received a denial from UHC stating that because we did not sign the WOL (Waiver of Liability) they were not going to process our claim.  We are not participating providers with UHC. 

Is anyone else having this issue?  Can they deny the claim if we do not want to sign the WOL or is it mandatory that we sign this form?

Any help will be appreciated.

Thank you
Coding / Orthopedic coding
« Last post by PMBS on September 20, 2018, 09:55:31 AM »
I recently billed Humana for the following codes:

29823 RT- debridement extensive
23120 51 Rt  These got paid- claviculectomy partial

29821 59 RT- synovectomy complete
23700 59 RT- Manipulation under anesthesia shoulder joint
29805 59 RT -Arthroscopy shoulder diagnostic
These got denied as bundled. 

When I looked in the CCI edits those codes are allowed with a modifier.   Any ideas on how I can rebuttal this? 

Thank you
Billing / Re: Claims billed to wrong payer
« Last post by Michele on September 19, 2018, 06:31:04 AM »
Did you include clearinghouse reports showing submission of the claim as well as practice management reports showing the history of the claim?  We include multiple reports all showing the steps taken with the claim.  The more documentation you can provide to support the fact that the claim was submitted timely, but to the wrong carrier and what was done following that.  If there is a huge gap from the original time the claim was submitted and when it was corrected and resubmitted you don't have much to stand on. 
General Questions / Re: Aprima
« Last post by amar@infinitecm on September 18, 2018, 02:28:45 PM »

We can help you with your additional AR work loads. We are currently assisting several physicians across the nation with various specialities. I can be reached at "" phone# (410)844-0850.

Amar S
Billing / Re: Claims billed to wrong payer
« Last post by venkateshwfm on September 18, 2018, 09:47:13 AM »
Hi...Thanks for the reply...But pat plan not included in ERISA group health plan....most of the claims are pending and unable to find solution...please help me...
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