Author Topic: Insurance audits  (Read 5798 times)

midwifebiller

  • Full Member
  • ***
  • Posts: 154
Insurance audits
« 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
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

PMRNC

  • Hero Member
  • *****
  • Posts: 4218
    • One Stop Resources & Networking for Medical Billers
Re: Insurance audits
« Reply #1 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  ::)
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Pay_My_Claims

  • Guest
Re: Insurance audits
« Reply #2 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.

Michele

  • Global Moderator
  • Hero Member
  • *****
  • Posts: 4708
    • Solutions Medical Billing
Re: Insurance audits
« Reply #3 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
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com

Pay_My_Claims

  • Guest
Re: Insurance audits
« Reply #4 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.

PMRNC

  • Hero Member
  • *****
  • Posts: 4218
    • One Stop Resources & Networking for Medical Billers
Re: Insurance audits
« Reply #5 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.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Pay_My_Claims

  • Guest
Re: Insurance audits
« Reply #6 on: August 24, 2009, 09:28:52 AM »
 ??? you don't say

midwifebiller

  • Full Member
  • ***
  • Posts: 154
Re: Insurance audits
« Reply #7 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

Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

Pay_My_Claims

  • Guest
Re: Insurance audits
« Reply #8 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.

PMRNC

  • Hero Member
  • *****
  • Posts: 4218
    • One Stop Resources & Networking for Medical Billers
Re: Insurance audits
« Reply #9 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.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Michele

  • Global Moderator
  • Hero Member
  • *****
  • Posts: 4708
    • Solutions Medical Billing
Re: Insurance audits
« Reply #10 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
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com

Pay_My_Claims

  • Guest
Re: Insurance audits
« Reply #11 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.

PMRNC

  • Hero Member
  • *****
  • Posts: 4218
    • One Stop Resources & Networking for Medical Billers
Re: Insurance audits
« Reply #12 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.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Pay_My_Claims

  • Guest
Re: Insurance audits
« Reply #13 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.

Michele

  • Global Moderator
  • Hero Member
  • *****
  • Posts: 4708
    • Solutions Medical Billing
Re: Insurance audits
« Reply #14 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
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com