Question

Dr. Smith recently started his own practice and has a high population of Medicare patients. His staff has not received formal training or education in billing practices, which has resulted in 85% of his claims being denied. Dr. Smith has privileges at Mercy General and performs a large amount of their inpatient and outpatient surgeries. Additionally, patients have begun to complain because their admission or procedure is denied or delayed because pre-authorization was not obtained or they received a letter from their insurance company denying part of or the entire bill because the procedure could have been done on an outpatient basis. Dr. Smith has hired a new office manager who is a health information management professional with billing and coding experience.

?Some of Dr. Smith's patients are receiving denials for their inpatient visit due to lack of medical necessity. In addition to the payer's review of the record, identify other external organizations that may perform periodic utilization and quality audits.

Answer 1

The 2 main reason for the denial is of 2 fold ,one is appeal to paper or write off,in order send a copy of phycisian note to the pay or and consider the claim to be unsuccessful and payment unable to obtain

Examining and understanding pastors initial claim determination might prompt a more successful response

In case of inpatient hospital provider must submit as a part of the clients inpatient hospital claim all related professional and outpatient services that were rendered on the date of the clients inpatient admission or one of the following dateimmediately before admission

That is,within the 3 calender days before the client inpatient admission for hospital that receive diagnostic related group reimbursement

Or within one calender day before the client inpatient admission for hospital that receive reimbursement other than DRG

Proffessional or outpatient services that must be submitted as a part of the inpatient hospital claim include the following services if they are rendered by the hospital or an entity that is wholly owned or operated by the hospital

Diagnostic services: it include outpatient laboratory and radiology services that are related to inpatient admission and submitted by physician and outpatient hospital providers.affected services will include the TOTAL and technical component.the professional interpretation component will not be included in the payment window

Nondiagnostic services: it include surgeries and other non diagnostic procedures and services that are related to the inpatient admission and submitted by the physician,outpatient hospitals, and other providers