Medicare Compliance & Reimbursement

Question: Our team is trying to  create an appeals policy and we’re looking for a little bit of guidance. Over the last year, the third-party biller we utilize submitted Medicare claims with clerical errors. Consequently, those errors led to several denials, and now we’re starting the appeals process for those claims. What is the first step we should pursue? Do we contact our Medicare carrier directly?

South Carolina Subscriber

Answer: No, you should avoid calling the Medicare Administrative Contractor (MAC) if possible. In fact, the reps at your MAC will simply tell you to submit your appeal in writing. In most cases, if you’ve submitted a claim and get a rejection due to a simple clerical error, you might be able to “reopen” the claim to fix your error rather than filing a formal appeal.

Nuts and bolts: Reopening is a process for correcting a minor error or omission on a claim without having to pursue the formal appeals process. You can request a reopening online, by phone, or by written request once the claim has been finalized. During reopening, you can change items such as the charge, the place of service, the quantity billed, the date of service (as long as it’s in the same calendar year), the procedure or diagnosis code, or a patient’s Medicare Beneficiary Identifier (MBI).

You can even add a modifier during the reopening process. For instance, if you’re seeking reopening of a claim that is denied as a duplicate, you can add a modifier such as 59 (Distinct procedural service), 76 (Repeat procedure or service by same physician or other qualified health care professional), 77 (Repeat procedure by another physician or other qualified health care professional), or others to confirm that the services are separate and not duplicates.

Limitations: Reopenings don’t work for every denial caused by a clerical error, however. You can’t use reopening to change the year on a date of service or to change billing provider information. Nor can you use reopening to add a line of service not billed on the initial claim, or for any change that requires additional documentation for a redetermination.