Posted by Carol Brown
We have probably all run into the above problem, that is, when receiving a conditional payment summary or final demand from Medicare one or more of the line item charges include multiple diagnosis codes, of which, some, but not all, are related to the claim.
In simpler terms, because I’m not sure the above sentence is structurally sound; say you have a fall where your client suffers a broken hip. You receive correspondence from Medicare and there is a line item charge for $100, with diagnosis codes related to fracture and, for example, diabetes. You have no way of knowing how much of the $100 is related to your case and how much is not since there is just one charge and multiple diagnosis codes.
So, naturally, you call Medicare. Ever helpful, they say, “Sorry, we can’t parse the charges out, you owe the entire $100.”
Now, this can’t be the law. Because after all, while Medicare has a claim for reimbursement, its only claim is for payments related to your case. Not for unrelated charges (such as diabetes in the example). And, it seems to me, that since Medicare has the claim, it must bear the burden of proving its claim. It can’t just say “too bad, pay the entire charge.”
How has anyone dealt with this issue, and has anyone had any success? I’m looking to see what others are doing in this regard.
By way of background, typically this issue is a result of a provider’s billing practices. If a provider billed these charges together, they typically show up in Medicare’s system together and then end up as one line item, whether the charges are related or not. As of our latest understanding of Medicare’s system, it does not allow for separation of these line items. There are appeal options to dispute claims pulls including the ability to request a hearing before an ALJ, but this is akin to your compromise request approach and can be time consuming. The viability of this approach would obviously depend on the amount of non-incident related included in the claims.