Author Topic: Insurance audits  (Read 6158 times)

Pay_My_Claims

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Re: Insurance audits
« Reply #15 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!!

midwifebiller

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Re: Insurance audits
« Reply #16 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
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

PMRNC

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Re: Insurance audits
« Reply #17 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
Linda Walker
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www.billerswebsite.com

PMRNC

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Re: Insurance audits
« Reply #18 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.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Michele

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Re: Insurance audits
« Reply #19 on: August 25, 2009, 07:52:55 PM »
Now didn't we all have fun!   ;D

Best of luck to your cousin.

Michele
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Pay_My_Claims

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Re: Insurance audits
« Reply #20 on: August 25, 2009, 08:09:31 PM »
Yes, now lets play another game......how about google the answer :-)

midwifebiller

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Re: Insurance audits
« Reply #21 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
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

PMRNC

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Re: Insurance audits
« Reply #22 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!! 
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Pay_My_Claims

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Re: Insurance audits
« Reply #23 on: August 26, 2009, 09:14:57 AM »
Kudos Linda.

midwifebiller

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Re: Insurance audits
« Reply #24 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
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com