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Insurance audits

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PMRNC:
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.

Pay_My_Claims:
 ??? you don't say

midwifebiller:
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

Pay_My_Claims:
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:

--- 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 ---

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.

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