Medical Billing Forum

Payments => Insurance Payments => Topic started by: midwifebiller on August 23, 2009, 03:47:47 AM

Title: Insurance audits
Post by: midwifebiller on August 23, 2009, 03:47:47 AM
This happened to another billing service recently:

State Medicaid program audited several providers, all who used the same billing service.
Medicaid found several billing errors and demanded a refund.
Providers said the billing service should pay the refund, since they should have known how to bill.
Billing service then tries to take the money from the biller's paycheck, but biller opposed, saying that was how she was trained.

All claims were billed from a superbill that the provider filled out and sent. Charts were not reviewed before sending claims.
Most of the refund was for services rendered and billed, but not covered by Medicaid for that provider type. Other problems were for services billed, but not documented in the charts, or the level of care was not supported by the chart.
What is the ethical answer here? Who is responsible for the refund?

~Kelli
Title: Re: Insurance audits
Post by: PMRNC on August 23, 2009, 08:28:46 AM
Can you point us to the actual case I would comment on a legal case, pending or non pending without having the case in front of me. Also we don't know contract terms and we don't know what was on those superbills before they were turned over to be billed. If there were coding errors we don't know who coded,
And the biggie..........  who got the money.. LOL  ::)
Title: Re: Insurance audits
Post by: Pay_My_Claims on August 23, 2009, 08:41:59 AM
My comment was basically somewhat the same, but in addition I would like to tell all billers to know your MEDICAID rules. Medicaid varies state to state, and when you accept an out of state provider to bill for, the first thing you should do is read up on the medicaid rules. I have had a few people in forums ask me from other states about NC medicaid. We have specifics about our medicaid that does not apply to other states. Don't just think because they marked it, it is so. Know what you can and can not bill so that when you see it, you can address it.
Title: Re: Insurance audits
Post by: Michele on August 23, 2009, 07:43:12 PM
I agree it's hard to comment without more facts.  But one comment I find interesting is that "Most of the refund was for services rendered and billed, but not covered by Medicaid for that provider type".  If it was not covered, how did the overpayment occur?  Wouldn't they have denied?  If I bill something that is not covered for the provider type it is denied.  Nothing is being billed incorrectly, just that the service isn't covered for that provider type. 

I'm curious to see more details on this one.

Michele
Title: Re: Insurance audits
Post by: Pay_My_Claims on August 23, 2009, 08:01:10 PM
we have had some to deny in error. we have also had medicaid audits where they overpaid on a particular hcpcs and in some cases underpaid. this happens sometimes when the fee schedule changes and claims are being resubmitted.
Title: Re: Insurance audits
Post by: PMRNC on August 23, 2009, 09:33:51 PM
there's a lot way off in that synopsis.. first it's a billing service, then it's "the" biller..  there's way too many chunks missing.
Title: Re: Insurance audits
Post by: Pay_My_Claims on August 24, 2009, 09:28:52 AM
 ??? you don't say
Title: Re: Insurance audits
Post by: midwifebiller on August 24, 2009, 03:37:59 PM
OK, OK, here are some of the gorey details.  :-)

1. Medicaid reimburses for case management, but only one per course of pregnancy.  OB fills out the superbills and indicates four case management visits during the pregnancy and sends said superbills to the billing service.  The Biller assigned to his account bills out all four case management codes, and all four codes are reimbursed to the OB. During the regularly scheduled audit, Medicaid discovers the three case management codes that should not have been reimbursed and demands a refund.

2. Midwife indicates a 36400 (venipuncture) on the superbill for a mandated newborn metabolic screen.  She sends the superbill to the billing service, the Biller assigned to her account bills the 36400 to Medicaid. Medicaid reimburses the code and payment is sent to the provider.  During the audit, Medicaid discovers that they have reimbursed over 100 of these venipunctures, but their requirements state that only a physician can be reimbursed for a 36400, so they demand a full refund.
[Sidenote:  depending on the state, Medicaid will or will not reimburse a provider specific code.  Here in Washington, you can bill whatever you like to Medicaid--if it's not a payable code, it will deny. Other states I have billed for are not as forgiving. They pay for just about any code you bill, then audit every provider regularly to recoup any erroneous reimbursements.]

So the providers think the billing service should pay the refund, the billing service wants to take it out of the Biller's paycheck.  Thoughts?
~Kelli

Title: Re: Insurance audits
Post by: Pay_My_Claims on August 24, 2009, 07:32:32 PM
Well all I'm going to say is this....The billing company should have been aware of the medicaid rules. The provider coded the superbill wrong (with or without knowledge, i don't know). I live in NC, and I know that you can't get an eye exam but once a year with medicaid. I know how many chiro visits you can get etc etc. If I bill for a NY provider what will I do........RESEARCH. Some billers just enter the codes and click submit. Medicaid is going to recoup from the provider regardless. He can't stop that. As far as the billing company, sounds like they need a legal representative. If the provider is smart, and if he made an honest error, that billing company will probably lose his account, if not already.
Title: Re: Insurance audits
Post by: PMRNC on August 24, 2009, 10:29:35 PM
Quote
So the providers think the billing service should pay the refund, the billing service wants to take it out of the Biller's paycheck.  Thoughts?

There are no opinions here that will matter no matter what. The monies were paid to the OB.. Only a judge in a court of law would decide who owes what who..but regardless the OB has to make good on any pmts made..the issue with the biller is to be settled in court, with the proper authorities and attorney's and judge/jury.

Our opinion is moot.

The only thing here we can pick up on is that ALL parties are libel one way or another.. in what form is up for the courts to decide.

I'd still be interested to see an actual case or suit on this.. I'm sensing there is none.
Title: Re: Insurance audits
Post by: Michele on August 25, 2009, 07:16:13 AM
I agree with all posted, but I'm still confused on one thing.  If only one case study is allowed per pregnancy then why did Medicaid reimburse 4?  Shouldn't they have edits in place that prevent this?

Also, just a thought, I have some providers that knowing that something won't be covered, want it billed out to show that the service was performed.  They do this knowing that they will be denied, and they can't and don't bill the patient, but they feel that if they provide the service they need to show that to the insurance carrier since it is in the patient's chart.  Maybe this is not an equal comparison, but it just made me think,  hmmmmmm.

Michele
Title: Re: Insurance audits
Post by: Pay_My_Claims on August 25, 2009, 09:11:45 AM
Michelle we have to do the same with DME, because we provided the equipment, and it is non-covered it is an "expected" denial, but we still have to bill because we provided the equipment. Carriers pay in error often. We now have a request for a recoup because BCBS paid twice on a claim. We have had the same thing with medicaid doing audits and discovering mistakes they made either in our favor or against us. This is why someone should be aware of the fee schedules, the allowed amounts, updates etc. Even outside of why the medicaid office paid, even worse to me the billing service NEVER questioned it.
Title: Re: Insurance audits
Post by: PMRNC on August 25, 2009, 09:36:48 AM
Quote
So the providers think the billing service should pay the refund, the billing service wants to take it out of the Biller's paycheck.  Thoughts?

Bottom line, they can go round and round over this.. The providers received the checks, Medicaid wants the money, the provider has to send it back.. right or wrong needs to be decided between the billing company and the provider after that, the billing company may or may not have E/O to cover their defense in court OR maybe if the doctor witholds the payment to the billing company the billing company has cause to go to court to recoup for "services" rendered. We don't know the contract, we don't know the state regs, we don't know the fee structure, we don't know squat beyond the provider needing to send back the money.  This is a contractual issue between the two contracted parties, opinions bare no meaning.
Title: Re: Insurance audits
Post by: Pay_My_Claims on August 25, 2009, 09:44:15 AM
Quote
So the providers think the billing service should pay the refund, the billing service wants to take it out of the Biller's paycheck.  Thoughts?

Bottom line, they can go round and round over this.. The providers received the checks, Medicaid wants the money, the provider has to send it back.. right or wrong needs to be decided between the billing company and the provider after that, the billing company may or may not have E/O to cover their defense in court OR maybe if the doctor witholds the payment to the billing company the billing company has cause to go to court to recoup for "services" rendered. We don't know the contract, we don't know the state regs, we don't know the fee structure, we don't know squat beyond the provider needing to send back the money.  This is a contractual issue between the two contracted parties, opinions bare no meaning.

I agree Linda. The provider will have to pay, and what happens between him and the billing service will have to be determined through some type of legal litigation's.
Title: Re: Insurance audits
Post by: Michele on August 25, 2009, 12:54:29 PM
I was enjoying the round and round!  Breaks up the monotony (as if we had time for monotony!).

Anyway I agree that opinion doesn't matter but it does make me wonder.  The provider gives the biller (not a coder) the superbill, the biller bills it as indicated on the superbill, and it's paid in error.  The provider wants to blame the biller for sending it out as his office coded it?  Is that right?

But as Linda said, provider got paid, provider gots to pay back.

Michele
Title: Re: Insurance audits
Post by: Pay_My_Claims on August 25, 2009, 01:18:13 PM
I was enjoying the round and round!  Breaks up the monotony (as if we had time for monotony!).

Anyway I agree that opinion doesn't matter but it does make me wonder.  The provider gives the biller (not a coder) the superbill, the biller bills it as indicated on the superbill, and it's paid in error.  The provider wants to blame the biller for sending it out as his office coded it?  Is that right?

But as Linda said, provider got paid, provider gots to pay back.

Michele


JMO it is correct to fault the biller. Just working the superbill makes you a data entry clerk, not a biller. A biller doesn't "code" the claim, but in this instance its a "benefit' issue. She/he should have redflagged that claim immediately!!  A provider can supply a wheelchair and a walker to a client, but Medicare won't pay for both. You either walk or ride!!
Title: Re: Insurance audits
Post by: midwifebiller on August 25, 2009, 02:55:48 PM
Thanks for all of your opinions--and I recognize that they are just that: opinions.  This is a very recent occurance and there is no court case. They are trying to settle the dispute themselves without attorneys and judges.  The last I heard, the billing service owner was considering reimbusing the providers the $$ they had to repay to Medicaid and not taking it out of the Biller's paycheck.

My cousin works for this company, so I was able to get a copy of the contract. Two points:  1) In performing the services required of it, [billing service]shall comply with all applicable federal, state, county and city statutes, ordinances and regulations. 2) [billing service] will use due care in processing the work of the Client, but it will be responsible only to the extent of correcting any errors which are due to the machines, operators or programmers of [billing service]; such errors will be corrected at no additional charge to the Client.  The liability of [billing service] with respect to this agreement shall in any event be limited to the total compensation for the services provided under this Agreement and shall not include any contingent liability.

So--yes Michele, the provider sent the superbill to the Biller (not coder), Biller bills as indicated, Medicaid paid it all (no edits in this state), then came back a year later and demanded a refund.  The billing service does not carry E/O insurance.  It sounds like their Billers need to be better researchers.
 
~Kelli
Title: Re: Insurance audits
Post by: PMRNC on August 25, 2009, 03:17:28 PM
Hey I'm all for playing devils advocate.. :)

Quote
The provider gives the biller (not a coder) the superbill, the biller bills it as indicated on the superbill, and it's paid in error.  The provider wants to blame the biller for sending it out as his office coded it?  Is that right?

Remember that the laws of abuse/fraud are verbalized in such a way that a biller SHOULD know certain things, it's not cut and dry they just do what they are told. We as billers are REQUIRED to know certain things. If WE Know that procedures are being put on superbills that were not done, and we bill them anyway, we are JUST as guilty as the provider.
But again..this is a separate legal issue from "who owes the money back". The insurance carrier doesn't give a Rats A&* who's fault it was, they want their money back. LOL
Title: Re: Insurance audits
Post by: PMRNC on August 25, 2009, 04:37:05 PM
Quote
2) [billing service] will use due care in processing the work of the Client, but it will be responsible only to the extent of correcting any errors which are due to the machines, operators or programmers of [billing service]; such errors will be corrected at no additional charge to the Client.  The liability of [billing service] with respect to this agreement shall in any event be limited to the total compensation for the services provided under this Agreement and shall not include any contingent liability.

Ok, I'll play..

Contracts are meant to cover contratual arrangements between the billing company and the client. HOWEVER if there are issues of legal concerns that deal with more than just "errors" the contract means NOTHING. People think having a simple "hold harmless" clause covers them and they don't need to have E/O.

NOW.. If I was the billing company, there's no way I would set a precedence like that and just give the provider the refund.. that's just me.
Title: Re: Insurance audits
Post by: Michele on August 25, 2009, 07:52:55 PM
Now didn't we all have fun!   ;D

Best of luck to your cousin.

Michele
Title: Re: Insurance audits
Post by: Pay_My_Claims on August 25, 2009, 08:09:31 PM
Yes, now lets play another game......how about google the answer :-)
Title: Re: Insurance audits
Post by: midwifebiller on August 25, 2009, 08:36:08 PM
That's the answer I was digging for--Linda would NOT set a precedence by just handing a refund over to the provider. Not that you'd ever be in this predicament, but (theoretically speaking, of course) how would you handle it if one of your employees made a billing error that resulted in a refund request from the insurance carrier?

~Kelli
Title: Re: Insurance audits
Post by: PMRNC on August 26, 2009, 08:42:58 AM
Quote
how would you handle it if one of your employees made a billing error that resulted in a refund request from the insurance carrier?

Glad you asked, first thing is I would consult my compliance plan. I'd take all the necessary steps to fix the error on our end but I would not just automatically assume financial responsibility. I've had a few situations where carriers wanted to be reimbursed and yes providers are not happy about it but that's the way it goes, each one has to be investigated and a determination has to be made on the action to either correct a mistake on our part or the providers part. I do know this.. if it was a client I billed on a % of collections, that money does get adjusted off. for example if a carrier wants $5000 back and we researched and found it was correct and the money had to be returned, the following invoice would reflect that because we are not going to keep money we received on money that has to go back, so if we got $400 from that $5000 (8%), their next invoice would reflect that $400 as a credit once we know the funds were returned. I require the provider to give me a copy of the check showing it was returned so that I can document it and of course adjust their invoice.

Again.. two lessons from this.. #1 Have proper insurance to do this work.. mistakes DO happen! I'm not a lawyer and I can't say for sure but it's quite possible if this provider took the billing company to court over this they could win.. OR even if it was an error the billing company could lose their business just trying to defend their mistake!
and #2 HAVE  A COMPLIANCE PLAN TO BACK YOU UP!! 
Title: Re: Insurance audits
Post by: Pay_My_Claims on August 26, 2009, 09:14:57 AM
Kudos Linda.
Title: Re: Insurance audits
Post by: midwifebiller on August 26, 2009, 11:10:21 PM
Thank you!  Audits and refund requests are indeed a part of the insurance cycle and it's nice to hear how veteran billing services handle these situations.

~Kelli