Optometry Coding & Billing Alert

Published on Wed Apr 07, 2004 PDF

Question: Medicare has been denying some of our claims, and I think it is mistaken. What should I do?

Georgia Subscriber

Answer: You can file a complaint with the state insurance commissioner or the department of labor if you have a problem with a private payer. But who are the proper authorities to contact when you have a problem securing payment from Medicare, Medicaid and even a skilled nursing facility?

If you receive a denial that you think is unfair, call the claims phone number on the EOB and talk to a claims person at your Medicare carrier. You may have made a mistake on the claim, or the rules may have recently changed. Sometimes, even Medicare makes mistakes, too.

If Medicare still can't see things your way after you place a call, there is a very well-defined administrative appeals process in the manual from your Medicare carrier or Medicaid program that you should follow.

For example, under the Medicare program, if you follow the appeals process correctly and meet all the filing deadlines and other requirements, you could be eligible to advance up the appeals chain and present your claim before an administrative law judge, then the Medicare Appeals Council, and finally to a federal district court.

Be sure to educate yourself on the appeals process and use it to your advantage.

If your claim is taking forever to be processed, you don't yet have access to this appeals process. There has to be a decision made - either a partial payment or flat-out denial --before you can pursue an appeal.

While you wait: Contact your state medical association or your practice's national medical-specialty society to make them aware of the problem you're having with the processing of your claim. These organizations are well positioned to tap into the source of the problem through their extensive network of contacts and resources.

Chances are that other providers are having the same problem you are, and if a medical organization receives several complaints, they are more likely to get involved.