Question

Melissa Smith is employed full time at a multispecialty health care provider’s office as a Coder I. She is highly productive and accurate with her work, and she has received excellent evaluations of employee performance. Melissa’s office manager asked her to meet in her office to discuss a patient complaint about a billing dispute because Melissa had coded this patient’s account. This claim was denied by the patient’s insurance company because medical necessity for submitted procedures was not justified. The patient was seen for shoulder pain, for which the provider ordered a shoulder x-ray; however, the patient started having chest pain in the office while awaiting the results of the shoulder x-ray. The provider immediately took the patient’s vital signs and ordered a chest x-ray and an EKG to determine whether the patient was having a myocardial infarction. Fortunately, both the chest x-ray and EKG were negative. The shoulder x-ray results were also negative, and an exercise stress test was scheduled for next week to further investigate the cause of the patient’s chest pain. The patient was prescribed ibuprofen 800 milligrams, to be taken every six hours for shoulder pain. Upon review of the submitted claim, Melissa and her office manager determined that the shoulder x-ray, chest x-ray, and EKG procedures were properly coded and reported; shoulder pain was appropriately coded and reported for the shoulder x-ray; however, shoulder pain was erroneously reported for the chest x-ray and EKG. They agreed that Melissa would submit an amended claim to the health insurance company to correctly report the chest pain code for the chest x-ray and EKG procedures.

a. How do you think the patient felt when he learned that procedures performed by the office had been denied by his insurance company?

b. How do you think Melissa felt for missing this important detail prior to the bill being submitted?

c. What should Melissa's office manager do in order to ensure this does not happen again?

Answer 1

a.The following feeling can be expressed by a patient when a claim is denied

• A tendency to not accept it
• Fear and anxiety related to pay from the pocket
• Loss of hope or disbelief on the medical team members
• Frustration and anger when things goes beyond hand

b.Melissa would have felt bad,disrespectful and tensed for the mistake done prior to the billing submitted.Acceptance of the act will be a secondary one till the confirmation from the management team as the normal response to any difficulty situation is denial.

c.The office manager should do the following so that this type of incidents doesn't occur in the future

• Regular training for the coder though experienced
• Checking out for the relaxation time to relieve the coders stress
• Make sure the coder always double checks before finalising or submission
• Get help of supervisor or seniors in case of doubts