Carrier: Medicare HMO
State: CA
CPT:Cataract Surgery
Service rendered: At Outpatient Hospital
I'm following up on an old claim about 1 1/2 yr old. The staff failed to obtain Authorization, verify, etc.. I called the outpatient center their record show they got paid by the Health Plan not the medical group. I think the reason they got paid is they're consider hospital and the doctor service consider professional? Usually if professional services done, medical group are the responsibility and hospitalization the health plan's. When billed the health plan they denied stated pt is capitated to xxxx Medical Group. Billed xxxx Medical group they denied for no Authorization, non-emergency, etc.. Do I still get a chance to appeal and to whom? The medical group or health plan? I feel is our fault, we should write-it off. The doctor does not want to write-it off., what else can I tell the doctor?
Max
State: CA
CPT:Cataract Surgery
Service rendered: At Outpatient Hospital
I'm following up on an old claim about 1 1/2 yr old. The staff failed to obtain Authorization, verify, etc.. I called the outpatient center their record show they got paid by the Health Plan not the medical group. I think the reason they got paid is they're consider hospital and the doctor service consider professional? Usually if professional services done, medical group are the responsibility and hospitalization the health plan's. When billed the health plan they denied stated pt is capitated to xxxx Medical Group. Billed xxxx Medical group they denied for no Authorization, non-emergency, etc.. Do I still get a chance to appeal and to whom? The medical group or health plan? I feel is our fault, we should write-it off. The doctor does not want to write-it off., what else can I tell the doctor?
Max
