Don't Go It Alone! U.S. Rehab Reimbursement Support Is Here for YOU!

Posted on in Product and Service Solutions

Dan FedorBy Dan Fedor, Director of Reimbursement, U.S. Rehab

One of the many benefits of a U.S. Rehab® membership is the easy access to reimbursement consulting. Many complex rehab providers have questions about claims, denials, payment rates, etc. There are many cases in which this reimbursement advice can save members from paying substantial amounts of money due to post-pay audits conducted by payers. U.S. Rehab wants to provide solutions to keep your business profitable and successful.

RAC Came to Recoup Payment

About two months ago, I received a call from a U.S. Rehab member who received an overpayment notification from the Recovery Audit Contractor (RAC) for two Medicare Advantage Plan power wheelchair claims (K0822 and K0856). The RAC was recouping both payments in the amount of approximately $16,000. They stated the reason for denial was because the coverage requirements were insufficient to support coverage guidelines because the face-to-face patient examination was on a form (template) and the 7-element order and detailed product description were not date stamped. Therefore, the RAC couldn't confirm if those documents were received within the required 45 days from the completion of the face-to-face exam. 

I reviewed the documentation and determined that these were valid denials per Medicare policy. When I informed the provider of this, he said these were not Medicare fee-for-service claims but Medicare Advantage Plan claims, and he had been reimbursed for similar claims (with the same errors) over the past several years without question and without recoupment. I informed him that the Advantage Plans are supposed to follow Medicare's policies, so these were valid denials. He asked me what his options were as he is a small provider and it would hurt financially to have to pay back $16,000. He asked if he could cite in his appeal the fact that they paid other claims similar to this in the past.

Focus on Medical Necessity, not Past Claims

I advised against that because they could then go back and look at those claims as well and possibly recoup them if those claims contained similar errors, which he said would put him out of business. Instead, I advised him to focus on medical necessity in the appeal because the medical necessity criteria was met, and these patients clearly qualified for the items that were ordered. He submitted the appeal with little time to spare. More than a month and a half went by, and he recently contacted me to thank me and let me know that the RAC overturned their original decision of denial! 

He won and gets to keep the payments he received for the products and services he provided to those qualified patients. That's the way it should be, right? Right! However, even though this was a successful appeal, the best appeal is one that is avoided in the first place. So, please remember to know the policies for the products you provide for each payer and adhere to them 100 percent of the time. Even if they pay (in error), it doesn't mean that it's okay, as they all conduct post-pay audits such as this one. 

If you have a situation with an audit overpayment request, please contact me at [email protected] or (570-499-8459 for assistance.

If you are not a U.S. Rehab member, click here for information on how to become one.