Medical Billing Forum

Billing => Billing => : CoderTechnically April 23, 2021, 12:51:18 AM

: Medicare payment dispute
: CoderTechnically April 23, 2021, 12:51:18 AM
Hi my name is Josh. Iím not a medical coder. Iím a software developer trying to do some research in this area for a project. I had a passing conversantion with and ENT sometime ago and he mentioned that sometimes they get underpaid by Medicare but itís not by enough to bother with. The example he used was a tonsillectomy. Supposed to be paid $1300 (for example) every time but sometimes the payment they get will be less. I was hoping that the subject matter experts here could clarify this for me.

1. How often does this happen in your experience?
2. How much are the payments off by when they are off?
3. If they are off does your office work to remediate or just let it go?
: Re: Medicare payment dispute
: Michele April 26, 2021, 01:04:20 PM
I'm sorry but this is too vague to answer.  I don't know why they would "sometimes be paid less".  There has to be some reason.  That is not a situation that billers would normally say happens.

Sorry, but the questions are relating to a situation that as a biller of over 25 years, I can say doesn't happen unless there is a reason. 
: Re: Medicare payment dispute
: kristin April 30, 2021, 11:03:35 PM
Like Michele says, there has to be a reason. And those reasons are many, depending on several factors.

In your example, you use a Medicare patient getting a tonsillectomy, which "pays" at $1300.

Was there another higher RVU procedure done at the same time? That will reduce the payment for the second procedure.

Was the procedure done IP at hospital, or OP at ASC?

Does the provider doing the procedure participate with MIPS, or no?

Did the patient have deductible left to be met when procedure was done?

Those are just a few reasons off of the top of my head.

: Re: Medicare payment dispute
: Michele May 02, 2021, 03:42:55 PM
Good points Kristin.