In the last article, we talked about the "L-Code" history and HCFA's implementation of the system. The "Claims Denied" area of information is very important for you to understand. I would like to refer you to an article written by Karyn Schibanoff, reimbursement specialist for AOPO, on this subject in the September 1999 issue of the O&P Almanac.
In the article she states, "Congress is focusing more attention on reducing the cost of health care to the Medicare Program. Claims being submitted to them are now undergoing scrutiny. More denials are being handed out than ever before. It is very important that you understand why your claim was denied and what options you have."
The reasons for the denial usually fall into five categories. Let's examine each one.
1. Lack of Medical Necessity: If you are denied for this reason you should appeal the denial. There are five levels to the appeal process: Review; Fair Hearing; Administrative Law Judge; Appeals, and Judicial Review. You must initiate this process within six (6) months of the processing date of Remittance Advice.
a) Review - This stage begins with a written request submitted as a letter or on a HCFA 1964 form. A reviewer who did not participate in the initial decision will examine all originals and any additional information that you feel would be helpful. If the original denial is upheld and your case is valued at $100 or more, you have the option of requesting the next level of appeal.
b) Fair Hearing - This hearing must be requested in writing within 120 days of the review decision. You can request that this be done in person or by phone. A date and hearing officer will be assigned to your claim. Before the hearing, the officer will personally conduct an "on-the-record" review of the case and supporting documentation that you have provided. The hearing officer has the authority to conclude the case at this point. If the review is not favorable, then the hearing is scheduled in person or by phone. Claims denied in the Fair Hearing and valued over $500 can proceed to the next level.
c) Administrative Law Judge - This must be requested in writing within 60 days of the Fair Hearing decision. Each level of appeals will put your claim in front of a new set of people entirely. It is important to be sure that at each level, you not delete any of the support material that you submitted previously. You may, however, submit additional information if it has become available. It would also be in your best interest to not assume that all of the information reviewed at the lower level made its way to the next level intact. Often, human error will cause the information to be either partially transferred or not transferred at all. These details should be personally verified to avoid further delays.
d) Appeals Council and Judicial Review - These involve claims valued at over $1,000 and each requires filing within 60 days of the previous decision. If your claim is denied in review and does not qualify for one of the higher levels of appeal because it does not meet the dollar limits required, then you have no further appeal option remaining.
2. Non-Covered Services: Non-covered services are items that Medicare excludes from its list of covered services. No appeals process is available here.
3. Incomplete Information: Medicare officials have stated repeatedly that many claims are returned for missing information. The reason code on your Remittance Advice will not identify what is missing so you need to focus on each detail to ensure that nothing is overlooked. NOS coding (not otherwise specified) is another source of claim denials. These codes designate that a service was provided that cannot be described by an existing code. You must include adequate supporting documentation when using NOS coding so that Medicare can identify the appropriateness and the reimbursement level for the procedure. These codes are also known as "99" codes. This has been a problem area in that there is no definition of what HCFA deems "adequate." As a result, a large number of denials are coming in with this reason indicated for the initial denial. While I'm sure that many of these claims may be going in with less than enough information to make a good judgment, without more detailed clarification of a process or formula identifying the essential elements to submit, the profession has its hands tied in trying to educate its practitioners and must follow the "lengthy" process of multiple resubmissions of information until HCFA says it has enough.
Often upon initial resubmission, the added information is not changed or is minimally expanded and the claim is accepted. While this process can be looked at as a protection mechanism by HCFA to prevent possible fraud and abuse, it also adds considerable unnecessary expense to the delivery of prosthetic and orthotic services. If one of the goals has been to reduce the overall costs of health care to Medicare, many people have begun to feel that a second goal is to also slow down the payment process. The savings to Medicare for slowing down the payment process is enormous. This may be one possible reason why problems, as I've described above, that could be easily resolved through meetings between HCFA and the organized field of prosthetics and orthotics, never get resolved. This is an area that "end user" involvement could prove to be very effective.
4. Duplicate Submission: Immediately investigate claims denied for this reason. Contact Medicare and ask why it believes more than one claim has been submitted. If resubmitted, find out what happened to the original claim.
5. Not Separately Payable: Codes denied because the service was considered inclusive or bundled into another code typically cannot be appealed. If you feel their interpretation is incorrect, you may present your case to your ombudsman, whose job it is to assist you with difficult cases.
When you are faced with a denial, your primary source of help comes from the office administrative staff of the clinic that you received your services from. If your provider has "accepted assignment" of your services, they cannot pursue the claims review process without your authorization to do so. It is in your best interest to have them do this for you and, if necessary, you may want to ask them to provide these services to you. While many offices may be doing this review already on a "non-assigned claim" basis, the current Medicare guidelines do require you to grant authorization to perform this service as your representative when the claim is "non-assigned." Your signature authorizing them to represent you in any needed claims review process is a necessary document that you will want to have to file in your chart if the claim is going in as "non-assigned."
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