New games from insurance companies

New games from insurance companies

Allen Dolberry

1/23/2019

Thanks to everyone for the responses. Here they are for your perusal.

 -We don't even want to get involved in the details. We play their own game
and deliver the rest of socks/ect on a different date. Works every time.



-We have billed multiple days4 socks per day until we’ve billed what was
supplied.also supply the patient that many on different days. Yes it’s a
game



-What do you mean per day? Or, what do THEY mean per day? Never heard
of any per day allowance. Also, we were told that Medicare covers only 6
socks per eligibility
period. Calendar year.



-We seldom ever bill out for more than one device at one visit. On occasion
but uncommon. I'm sure this is a way to stop those DME companies that bill
out illegally every day and this is a easy way to reduce the bills. Set up
the computer algorithm to just deny at a certain level and you reduce the
degree of illegal companies.



-If they are not MC pts then they are not bound by the MC standards and CMS
guidelines (unless they are Medicaid, which is a different species);
therefore, reply to the insurance carrier that they are in breach of
contract. Tell them there is nothing (and read the fine print to be
certain) that says only medicare reimbursement rules & conditions apply to
all patients. Ask them to re-consider these non-MC patients using the
regular pt guidelines. They think you don’t know that CMS doesn’t govern
regular patients/contracts. The state dept of insurance monitors them…



For those who have a preauth, the insurer is actually breaking the law.
They cannot provide a preauth # for codes/quantities/levels of service and
then deny them upon presentation of the actual bill. That is illegal in
most states. I’d have to look up the technical definition of this game,
but it is a game. Send them – in writing—to a manager or above – a
statement of disagreement, the case#, preauth#, etc. and ask them nicely to
send the payment due since it is a clear violation of good faith bargaining
and insurance law to provide a preauth and then deny the claim for the
exact items covered in the preauth.



In all things that require more than one item per patient per date of
service be very careful. Make sure the contract allows this before you do
it. Even if they say no preauth is needed, get one if you can. This way
they are almost required to pay the bill.



If it were me, for those two carriers, I would only do one thing per day
and be very detailed in my work to ensure payment. (Well, I’d give them 2
socks at a time; but, surely not 9). Yes, that means the patient must come
back. If they complain, tell them to call the 800# on the back of their
insurance card. That’s not your circus and you aren’t a clown. If the
company gets enough patient complaints, then they’ll start to be more
reasonable.



If they say a preauth doesn’t guarantee payment, ask them for the page # of
the contract that contains that statement that is contrary to state law so
you can send it to your State dept of Insurance. They won’t want that
investigation…



I know you have it in your mind to do the best for the patient. That’s
great but you have to balance that with getting paid. If not, it’s a
doggone expensive hobby being a CPO.





-The only helpful hint I can give you is not to put RT and LT on the same
line on the claim, if you think this is where the problem is. They are not
recognizing the two different modifiers so with a quantity of 2 units on
one line the system kicks one unit out as being too many on one day.



We had that with bilateral AFO's, and of all things, also diabetic shoes.
BCBS in the fall of 2017, started paying only for 1 unit of a pair (2
units) of shoes and/or DM inserts when we put RT LT 2 units on one line
item. They had always paid correctly for decades before that. They refused
to correct it on their end plus could not tell us if they paid on the RT or
the LT. We first started sending in appeals that continued to bounce back
as Denied. Processed Correctly regardless of how simply we worded our
appeals. After a phone call to our BCBS area rep last spring she said she
was well aware that something was changed in the software across the nation
for making claims pay easier, however they are aware that this in not the
case and not sure when it is to be fixed. She suggested that for the future
claims to put everything on individual lines. Claims like this appear to be
paying corrected she said at the time. Then we sent in Corrected Claims
with each unit on a separate line and let them sort it out.



Recently even Medicare sent out instructions to put RT and LT's on separate
lines.



Hope this helps if this fits your scenario.



-You can check the CMS MUE (Medically Unlikely Edit) list here for the CMS
maximum allowable per code and if they're only allowing less than what's on
the MUE list then you should tell them to look at this list.

Go to <URL Redacted> and
look at the bottom where they have a link to the DME Suppllier Services MUE
table.



One additional thing we've found is that some payers (and medicare will be
rolling this out too in a few months for claims with dates of service (DOS)
on or after 3/1/2019) will want the LT and RT sides split on separate lines
but they won't tell you that. They'll just tell you their denying for max
allowable units but their system is really set at half the max number
because they're expecting each side on it's own line.

Medically Unlikely Edits - Home - Centers for Medicare & Medicaid Services
< <URL Redacted>>

www.cms.gov

Notice: The MUE file for the third quarter of 2014 was updated to contain
two additional fields of information.One field indicates whether each MUE
is a claim line or date of service edit. (See MLN SE1422.) The second field
provides the rationale for each MUE.









--
*Allen Dolberry CPO*