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Claim Rejected Claim Filing Indicator

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RichardP:

--- Quote from: pecbilling on November 22, 2013, 11:11:54 AM ---... the patient has Workers Comp insurance for anything related to his back (our claims are not) but that is what Medicare has as the patient's primary insurance ...
--- End quote ---

Workers Comp is insurance for a very specific purpose.  If that purpose doesn't exist (workplace injury), Workers Comp is irrelevant to a patient's health care needs.  Our experience is that Medicare does not ever pay as secondary on a Workers Comp case (I realize that maybe this is different in other MAC jurisdictions?).  We don't ever bill Medicare as secondary on a Workers Comp case. 

Workers Comp is not a primary insurance, and should not be listed as such with Medicare.  The patient's primary insurance when Workers Comp is not involved is what should be listed as primary with Medicare.  If Medicare is the patient's only insurance outside of Workers Comp, that is what should be on file with Medicare as primary.

To repeat:  the problem is that Workers Comp is listed as primary insurance with Medicare.  It shouldn't be listed with them at all.  The patient should contact Medicare and have them list as primary whatever other insurance they have outside of Workers Comp.  The patient has to do this.  Medicare will not respond to a request from any other party.

shanbull:

--- Quote ---To repeat:  the problem is that Workers Comp is listed as primary insurance with Medicare.  It shouldn't be listed with them at all.  The patient should contact Medicare and have them list as primary whatever other insurance they have outside of Workers Comp.  The patient has to do this.  Medicare will not respond to a request from any other party.
--- End quote ---

I'm bewildered here too. The patient did call Medicare to discuss this, and apparently the treatment in question has nothing to do with the diagnoses in the Worker's Comp case. So Medicare should have already updated their system with this info, as they did hear it from the patient, and told the patient that this treatment wouldn't be confused with the Worker's Comp injuries. Once this has happened I generally do not run into these problems. pecbilling, the only reason I can think of as to why this claim may have gotten flagged is one of the diagnoses is an "accident/injury" code to Medicare which automatically places the claim in the wrong category. Would you mind sharing the exact CPT's and ICD's on the claim? If those check out, then I definitely do not think coding is the problem, period.


--- Quote --- Our experience is that Medicare does not ever pay as secondary on a Workers Comp case (I realize that maybe this is different in other MAC jurisdictions?).  We don't ever bill Medicare as secondary on a Workers Comp case. 
--- End quote ---

I'm not sure how to explain this without getting really complicated, but I will try. We do not bill Medicare secondary to worker's comp or auto, but in some cases Medicare is listed in the claim as the secondary insurance because we are required to still bill the liability carrier in order to collect interest once the case goes into arbitration or suit. We do need that denial and then we turn around and bill Medicare. So technically speaking, I guess we are billing Medicare as secondary, but not with the expectation that both the liability carrier and Medicare will pay. It's one or the other, with the plan that the money will eventually be reimbursed through settlement. Medical insurance payment is a stopgap measure to keep money coming in for the time being so the clinic doesn't go broke, without forcing the patient to pay thousands of dollars upfront and wait for years until the case gets settled. So it gets kind of tricky to identify Medicare as "secondary" because it's in that spot, yes, but the setup is not the same as just a regular claim with both primary and secondary insurance. What happens sometimes is Medicare messes up on a claim unrelated to worker's comp, and assigns it to the worker's comp case and this is what results. They consider themselves "secondary" for purposes of the worker's comp liability, and they are expecting an appeal with a denial from worker's comp for that claim attached. The problem is, they should have a different insurance setup for medical claims unrelated to the case (basically, two separate accounts within the patient's Medicare plan) so they get processed normally, because those claims are not supposed to go to worker's comp at all (so a denial would not exist, obviously), and it sounds like somehow that did not happen despite the patient calling and asking them to do this. So I believe it's either because Medicare did nothing, or the claim itself has an indicator that is causing it to be sent to the wrong category (worker's comp claims instead of purely medical claims).

pecbilling:
Thank you so much for your help. I just received notice again that Medicare rejected the claim even with the STAND ALONE on it (which I knew from the moment she told me to do that it wasn't going to work. It's just like you said the claims go electronically no one is going to see that!) Right before I checked this site I thought to myself I wonder if taking the patient's insurance information completely out and starting all over will work and then saw you suggested it as well so I'm going to try that also. My next step will be calling Emdeon and hoping they can help me because I've never experienced anything like this usually if Medicare has some other ins as primary (car, workers comp etc) they still accept the claim and then send a denial stating pt has other insurance as primary. This patient's claim has become the biggest thorn in my side!

The exact CPT codes and ICD's are: 1st claim: CPT 92004  ICD: 366.53 and 224.6  CPT: 92250 ICD: 224.6 and the second claim CPT is 66821 ICD 366.53

Any other suggestions would be greatly appreciated because I am NOT calling Medicare again about this...the person I spoke to yesterday was completely useless!! I will also let you know if taking the insurance information all the way out and entering again works.

Again thank you so much for your help  :)

shanbull:
I checked those codes and there's nothing about them that should be flagging the claims, so we can definitely cross that possibility off the list. Let us know how things go with resubmitting :)

pecbilling:
I took the patient's insurance out and re entered it and then resubmitted the claim and it was accepted by Medicare!! I think I might be on the road to finally getting this claim paid, thank you so much for your help   ;D

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