Medicare Compliance & Reimbursement

Myth: Your best chance of overturning a denied claim lies in the device manufacturer's appeal on your behalf.

Reality: The most effective way to stay on top of your appeal is to shepherd it through the process on your own. The device manufacturer might help guide you, but the ball should stay in your court.

Example: Your Medicare carrier denies a claim for cervical disc replacement. The disc manufacturer offers to take over the appeal for you.

Although the manufacturer has an interest in getting the denied portion of the claim paid (to keep the provider happy so he continues to use their product), and it would save the headache of the office doing the appeal, "I prefer to get the information from the manufacturer so I could track the appeal from beginning to end," says Rena G. Hall, CPC, coder and auditor with KC Neurosurgery Group in Kansas City, MO.

"I may get information from the product manufacturer regarding the device, surgical technique, etc., but I would want to know that the information being presented on appeal follows coding policy and guidelines," says Ruby O'Brochta-Woodward, BSN, RN, ACS-OR, coding and appeals specialist with Orthopedic Consultants, PA in Minnesota.

"As a rule, I use the information from manufacturers as just that -- information -- but not as my coding policy," O'Brochta-Woodward says.

Tip: If you're considering following the device manufacturer's lead on your appeal, ask their rep what its appeal success rate is, Hall says.

"I would ask them how frequently they follow up on the appeal, whether they submit and then let the appeal go, or if they contact the provider to check on the payment and contact the payer a second or third time if need be," Hall advises. In addition, she suggests asking whether the manufacturer will appeal all payers or just one, and whether it checks to ensure that the claim made it into the carrier's hands.

"I am very particular about how the appeals are done, which is why my success rate is so high (over 90 percent)," Hall says.