Payments > Insurance Payments
Insurance audits
Pay_My_Claims:
--- Quote from: Michele on August 25, 2009, 03:54:29 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
--- End quote ---
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:
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
PMRNC:
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?
--- End quote ---
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
PMRNC:
--- 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.
--- End quote ---
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.
Michele:
Now didn't we all have fun! ;D
Best of luck to your cousin.
Michele
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