Payments > Insurance Payments
Insurance audits
Michele:
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
Pay_My_Claims:
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:
--- 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?
--- End quote ---
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.
Pay_My_Claims:
--- Quote from: PMRNC on August 25, 2009, 12:36:48 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?
--- End quote ---
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.
--- End quote ---
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:
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
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