Meciare Pre-Payment Audits
Jim DeWees
Description
Collection
Title:
Meciare Pre-Payment Audits
Creator:
Jim DeWees
Date:
1/11/2013
Text:
Hello Everyone, As I posted a few weeks ago, I got my FIRST pre-payment audit at the end of November. I quickly put all the information together, and submitted it back to NGS (owned by Anthem Blue Cross). I have been VERY VERY cautious about doing any Medicare work, and I have followed the rules precisely!! I have the patients visit the doctors for an evaluation specifically for a prosthetic leg. I send an example of what needs to be in their chart notes, specifically mentioning the desire of the patient to get a leg, and his/her potential or abilities, giving the exact wording for the K3 or K2 level. I got my FIRST response back from NGS yesterday, and even with ALL of the paperwork, with it being PERFECT by their standards (I would give anyone a large sum of money if they could find ANYTHING wrong with the paperwork), NGS denied the claims, stating that the information furnished does not substantiate the need for this level of service.
I called NGS this morning to find out WHO reviewed this claim, and HOW did they determine that what the physician who KNOWS this patient did not submit enough information for determination for a K3 level? This patient had NO limitations before his Below-knee amputation. With a prosthetic leg, this man can do EVERYTHING that a K3 level amputee is defined as doing.
So, here's a question for everyone: Has anyone of us fought with NGS or their Medicare contractor to get the actual name of the MD who reviewed the files or the claims? It is my understanding that by law, the insurance companies MUST provide the names of the physicians that work for them, because when these physicians review the claims and make medically based determinations for these patients, these physicians are now treating physicians. Has ANYONE been able to get the insurance to provide these names? I am expecting a call from some manager from NGS to talk to me about this situation. I have demanded to get the name and information of the actual physician that reviewed the claim and basically REVERSED the information that the REAL treating physician wrote, as well as all of MY documentation. I am actually considering submitting a video of this man walking, going up stairs, ramps and climbing up a ladder. This man is VERY active, and it is well documented.
They explained that my NEXT step is to re-submit it all again for re-determination. I have a colleague coming to my office this morning to go over the paperwork with me, and they know how to re-submit these claims.
But, what I am thinking of starting here is ALL of us need to get the names of these physicians, and start a campaign against these insurance companies, and also make it personal against these individuals that are sitting in a closet somewhere, thinking they are insulated or protected while they make these horrible decisions that DO impact the lives of the amputees, AND also the lives and liveliehoods of the prosthetists.
We can do this!! We SHOULD do this, and make a list of these physicians that are making BAD decisions on these audits. I honestly question whether or not they even LOOK at the paperwork that is submitted. Does anyone agree with me? Will anyone else out there join me in getting the names of the physicians that are making these decisions of medical necessity for our patients???
Please let me know what your thoughts are here. THanks
Jim DeWees, CP
I called NGS this morning to find out WHO reviewed this claim, and HOW did they determine that what the physician who KNOWS this patient did not submit enough information for determination for a K3 level? This patient had NO limitations before his Below-knee amputation. With a prosthetic leg, this man can do EVERYTHING that a K3 level amputee is defined as doing.
So, here's a question for everyone: Has anyone of us fought with NGS or their Medicare contractor to get the actual name of the MD who reviewed the files or the claims? It is my understanding that by law, the insurance companies MUST provide the names of the physicians that work for them, because when these physicians review the claims and make medically based determinations for these patients, these physicians are now treating physicians. Has ANYONE been able to get the insurance to provide these names? I am expecting a call from some manager from NGS to talk to me about this situation. I have demanded to get the name and information of the actual physician that reviewed the claim and basically REVERSED the information that the REAL treating physician wrote, as well as all of MY documentation. I am actually considering submitting a video of this man walking, going up stairs, ramps and climbing up a ladder. This man is VERY active, and it is well documented.
They explained that my NEXT step is to re-submit it all again for re-determination. I have a colleague coming to my office this morning to go over the paperwork with me, and they know how to re-submit these claims.
But, what I am thinking of starting here is ALL of us need to get the names of these physicians, and start a campaign against these insurance companies, and also make it personal against these individuals that are sitting in a closet somewhere, thinking they are insulated or protected while they make these horrible decisions that DO impact the lives of the amputees, AND also the lives and liveliehoods of the prosthetists.
We can do this!! We SHOULD do this, and make a list of these physicians that are making BAD decisions on these audits. I honestly question whether or not they even LOOK at the paperwork that is submitted. Does anyone agree with me? Will anyone else out there join me in getting the names of the physicians that are making these decisions of medical necessity for our patients???
Please let me know what your thoughts are here. THanks
Jim DeWees, CP
Citation
Jim DeWees, “Meciare Pre-Payment Audits,” Digital Resource Foundation for Orthotics and Prosthetics, accessed December 24, 2024, https://library.drfop.org/items/show/234505.
