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Patient measurements on claim forms
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Re: Patient measurements on claim forms
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Steve Verno
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May 9 11 3:37 AM
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It could be that she avoided your question because there may be no way to avoid a review.
NUCC has nothing as to where to put this on the claim form. The insurance company may require reviews when this type of service is rendered. Attaching a copy of the medical record document may assist with the claim processing, but if the insurance company requires a review due to many incidents of fraud, then it may be hard to avoid a review. Last, in our profession, we do NOT try to bypass audits or reviews. We submit claims that are 100% true, accurate, and correct and which are supported by 100% true, accurate and correct documentation of the service that was actually rendered in accordance with applicable industry standards and guidelines and which are medically necessary.
More on Hedis can be found here:
http://www.ncqa.org/tabid/187/Default.aspx
On a different note, I had one provider who was submitting claims with level 4 or 5 E/M codes. 99% of his patients were super sick therefore justifying the high levels of E/M. All levels were clearly documented and he passed every governmental audit thrown his way. One HMO downcoded his claims to level 3 using HEDIS nd NCQA as the reason. He was not par with the HMO. He sued the HMO because they downcoded without record review. The HMO put pressure to get him to contract. I looked at the contract and several pages were devoted to HEDIS. He refused to contract, so the HMO put pressure on the hospital and his patients to contract. Long story short, he won the lawsuit, sold the practice and retired from medicine. It was a 6 year battle in the courts but he stuck with it.
Last, another doctor and a different HMO, the HMO demanded numerous medical records. When checking further, the record requests were not on claims in process. The HMO was doing a different kind of audits. We demanded HIPAA authorizations before we would release the records. The HMO yelled HEDIS and MCQA to get us to backdown, but we still demanded the authorizations because the audit was not per HIPAA Treatment, Payment and Healthcare Operations. In the end, they never got the records. They started submitting refund demands, which were also denied. The patients had HMO benefits under ERISA. I used ERISA to fight back. The HMO went to the State but the state backed off when informed about ERISA having jurisdiction.
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Association News
Medical Billing & Coding Education from the MAB
Continuing Education
Management Advice and Training
Questions Asked More Than Once
Help Wanted - Billing and Coding
Non Billing Talk
The Venting Area (Clean posts please)
Medical Coding and Billing News
Fraud and Abuse
Health Insurance - Provider Contracting
ERISA
Tricare
Workers' Compensation
General Medical Billing Questions
Appeals
Accounts Receivables (A/R)
Refunds
Auto Accident Issues
Medisoft Technical Support
Medical Software Technical Support Questions Other than Medisoft. No Investigation Questions!
General Medical Coding Forum
CPT Coding Questions
HCPCS Coding Questions
ICD-9-CM Coding Questions
Evaluation & Management Coding Questions
Acupuncture Billing and Coding
Ambulance Coding and Billing
Cardiology Coding and Billing
Chiropractic Coding and Billing
Dental Billing and Coding
DME Coding and Billing
Emergency Department Coding and Billing
Family Practice Coding and Billing
Hospital Inpatient and Outpatient Coding
Hospital Billing, Appeals and Collections
Internal Medicine Coding and Billing
Laboratory Coding and Billing
Ophthalmology Coding and Billing
OB-GYN Coding and Billing
Pain Management Coding and Billing
Pediatric Coding and Billing
Podiatry Coding and Billing
Physical Therapy Coding and Billing
Psychiatry Coding and Billing
Radiology Coding and Billing
Surgery Coding and Billing
Neurology Coding and Billing
Urgent Care Coding and Billing
Provider Compliance
Billing Center Compliance
HIPAA
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Patient measurements on claim forms
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