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Insurance audits

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midwifebiller:
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

PMRNC:
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  ::)

Pay_My_Claims:
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:
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

Pay_My_Claims:
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.

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