Coding > Coding
Audit
RichardP:
--- Quote from: danielmanske on February 27, 2015, 01:14:28 AM ---I've seen nothing here to refute my interpretation.
--- End quote ---
If you can provide answers to the following questions, that would be useful for those who pass by these parts in order to learn things.
1. Do you, or the company you work for, have a contract with the Medicaid HMO in question?
2. Have you discussed these issues with a HealthCare Attorney who knows your state's Medicaid laws?
3. If the answer to Q2 is "Yes", does the Healthcare Attorney agree with your interpretation?
4. If you lose on all points to the Medicaid HMO (assuming that they push it that far), do you or the company you work for stand to lose the ability to bill Medicaid for your state?
I'm curious to know how your situation gets resolved, whenever that happens.
PMRNC:
Richard made excellent points.. all spot on.
My own take is that the AMA is no different than CMS..they have an "INVESTED" interest as well as a monopoly when it comes to CPT. You sure don't see us discussing a new PROCEDURE code system like we do diagnosis coding systems now do we? :o ;) ;)
danielmanske:
Answer to Richard's questions 1-3, yes, Q4, unknown though not a likely scenario.
After last phone conference, they reduced their request for repayment by 70% after giving "credit" for agreeing that most of the charges conform to Appendix C, CPT.
They stated that they can go back beyond the 18 month limit imposed by NJ law because there was a "pattern of inappropriate billing" regarding the use of 99211 for immunizations.
This will be contested. There is a conceptual basis for using this code for immunizations as it conforms to all aspects of a 99211 though I did admit that on review of CPT wording elsewhere it does state that a more specific code is available.
Regarding the comparison of AMA to CMS, there is a distinct difference between the two. CMS is an agent of the state, with the full enforcing powers of the federal government. It is above the fray of commercial give and take and, as you well know, makes its own rules that trump any others. And unless something changes, it will increasingly dictate health care delivery and payment.
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