Re: Medicare Denials

Re: Medicare Denials

Jim DeWees

1/18/2013

Hello Everyone, First off, sorry for the lenght of this email....I honestly TRIED to keep it short. On this issue of finding out WHO is the MD, RN or whatever who is working for the big insurance companies, who also are the administrators for Medicare, and the same physicians most likely. We DO have the right to find out who these treating physicians are, and hold them personally accountable for their decisions on medical necessity for the patients. I want to share an experience that I had a few years ago, dealing with a big insurance company and a prosthetic claim for a patient. This patient is a professor of a local university, and his BK prosthesis was over 9 years old, and in 3 pieces, literally. He finally caved in and decided it was past time to get a new leg. Just to make it short: 1. No precert would be granted2. HR director of university got involved and got pre-cert ( I called her and expressed my frurstration)3. Claim not paid, stating no precert on file4. HR called and pointed out that SHE had a copy of the pre-cert. (I called her again and expressed my frustration).5. Claim not paid, MD at insurance claims it was NOT medically necessary6. HR director called and got that fixed...and got the name of the physician ( I had called her AGAIN.......)7. I got the same name from a nurse at the insurance of the physician, and his home city.8. I FINALLY got paid for the prosthetic leg.
 The Denier: He was an oncologist working for another state university hospital (2 states away from my state), and was the director of oncology. He actually was on the board of directors for the local Gilda Radner Cancer support group.
I called the hospital, and asked if there was a conflict of interest, and there IS a BIG conflict and that is NOT allowed to work for the hospital and for an insurance company. I faxed a copy of the denial WITH his signature on it to the hospital for them to take action. (He didn't keep that position for long, I checked the website to see if he was replaced, and he was). I also called the Gilda Radner group director and explained who this doctor was, and that he worked for the insurance and denies claims. They have cancer patients that die while waiting and fighting for coverage and treatments by this insurance as well. This person was REALLY upset that this physician was such a 2 faced person, acting so genuine to them, BUT he worked for the company that allowed some of their members to die without the proper treatments. He was booted out. But, my point is that we CAN get the names of these treating physicians. We do have legal avenues to get these names. I am not saying that we need to personally stalk these people, or try to destroy them in any way. BUT, we can file lawsuits against them for various reasons, and we don't even need a lawyer to file a lawsuit. We won't win any case without a lawyer, but we can definitely tie them up and cost these insurcance companies a LOT of time and legal work to prepare to defend their physicians, even if these cases never go to a trial.
But if we can show them that we ARE NOT going to just roll over and take this, they might realize this is not worth their time doing things in this manner of pre-payment audits. AND, just maybe some amptuee WILL be that upset over this, who IS in a financial position that WILL take a case all the way to the courtroom. Or maybe some of us will get an attorney to take it all the way to a courtroom. But we can bog them down, and show them that this delay of payments are NOT saving them ANY money. We should also report them to their state licensing boards and question them as to IF they are doing what is in a patient's best interst, OR are they being paid in a manner that would influence them to deny claims for financial gain. I think most state boards m(which are made up of other physicians), and some of these OTHER PHYSICIANS are also sick and tired of fighting with insuracne companies, would take this very seriously, and maybe even take very strong actions against fellow physicians that work for insurance companies and causing us all grief (including physicians). It is NOT CMS that is doing these pre-payment audits. In my case, it is NGS, which is owned by Anthem. THEY are the ones that have hired physicians and nurses that are holding these claims up. THEY are the ones that have denied my first couple audits, and THEY would not even tell me WHAT was missing or what was the problem. All of our regions have a contracted insurance company who is the one doing this dirty work to all of us. Back to my first,and current Audit.......FINALLY a supervisor from NGS (Anthem) called me (basically to keep me from calling daily and harrassing their level 1 and level 2 employees....I know they were NOT happy with what I had to tell them.....) and she told me that the ONLY thing missing was that I did NOT submit the signature attestation for my own signature. (The level 1 and level 2 employees couldn't seem to read even that part of the computer message to me). I pointed out to her that MY name and MY signature are already on file, and that I have my Medicare Provider ID number, and my signature is all over the application and the approval of my provider ID number. BUT they are too stupid to put all that together I guess.....well, that is just their goal, to find ANY reason to deny the claims. She said that it is ALWAYS a good practice to send my own attestation form for my signature. I had NEVER been told this before by CMS or NGS, it was never mentioned in the video training that NGS (Medicare University) ever mentioned. Again, just a little trick they have to deny claims. So, as soon as I was off the phone with her, I sent in 18 pages by fax to them with all the other paperwork that I felt might influence them to approve these claims. One issue was how I mentioned that the patient walked out of my office on the FIRST DAY of having a leg, with a walker. Then a week later came in with a cane....well, in THEIR opinion, the use of a walker or a cane is NOT a K3 level amptuee. BUT there is progress, and by now (3 months later) this man is walking with NO assistive devices, and so I sent the LCD copies that talk about this progress and how it is to be handled, and documented (thanks to someone on this list who sent it to me), and also a copy of the K3 definition from the CMS policies. It is crazy, and they are ruthless on how they do things. BUT the bottom line is, they MUST (it is required)have some medical professional review this file, and this physician DID deny the level of service due to lack of info that supports it....and so THEY are calling the patient something lower than a K3, even though 3 other healthcare providers have documented the level of function as a K3. This person MUST be held accountable for going against the actual treating physicians. We can ALL find these names, they MUST tell us. (It is the law). The patients also can get these names, OR give us the power to ask on their behalf. We must go after these physicians and nurses and expose them, file lawsuits against them, and make a bold accusation that they are ONLY doing this for financial gain of their employer (Anthem in my case). Report them to their state boards as well. Let me know what you think about this......I think this is a legitimate approach to this problem. Hopefully, in a short time frame, the insurance companies will not be able to find physicians to review these claims, OR these physicians will be terrified to deny a claim UNLESS they have REAL proof that the info is missing. Hopefully, they WILL do a better job. I am sure that about ALL physicians would be terrified to risk losing their medical license or having their right to practice medicine revoked, JUST to make more money for their employers (the insurance company), no matter WHAT kind of bonus the insuracne companies offer them in return. They have all worked too hard to get their degrees and to become a physician, and surely would think twice about losing that. OK, yes, it is a Friday night, and I am still thinking about this mess. BUT I am about to go and have a great, long weekend. Thanks again everyone. Jim DeWees, CP
 > Date: Fri, 18 Jan 2013 10:30:38 -0500
> From: <Email Address Redacted>
> Subject: [OANDP-L] Medicare Denials
> To: <Email Address Redacted>
>
> Hello Colleagues and Guests,
>
> There is an issue coming to the forefront among our other issues with
> CMS. Jim DeWeese alluded to these recently in one of his posts. There
> are claims being denied by CMS physicians or others within CMS, that are
> overriding the decisions of multiple treating physicians. As such, these
> persons and their clinical decisions become a part of the patients
> official medical record and I believe they may also be liable for their
> decisions. The patient and the various providers of medical care have a
> right to these records in their entirety. However, it is very difficult
> to get the name of the person making these decisions within CMS when
> claims are denied and it is even harder to get a copy of their signed
> written medical report.
>
> I believe this issue needs to be examined in detail and followed up
> accordingly. Is anyone out there having success with this issue? If so,
> I would like to hear how you are getting these records released.
>
> Thank you.
>
> Wil Haines, CPO
> MaxCare Bionics
> Avon, IN 46123
>
>