These examples show how you may be able to recoup part of your denied claim, even if you have to give up a portion of the reimbursement.
Case in point:
A durable medical equipment company is appealing a Recovery Audit Contractor recoupment involving what the RAC claims to be noncompliant billing for a power wheelchair. The billing allegedly violated some bundling rules that are part of a local coverage decision, reports attorney Amy Fehn, whose law firm is handling the appeal for the DME provider."The issue involves armrests," Fehn explains. The local coverage determination (LCD) policy "has a chart saying if you are providing this code and this code, they should be bundled with a certain other code." The guidance, however, on the bundling issue isn't very clear, she adds.
And, "even if there is an error, it may be a $20 error whereas the RAC is trying to disapprove thousands of dollars by denying the whole claim," says Fehn, with Wachler & Associates in Royal Oak, Mich.
Another example:
In Florida, "providers have had Part B rehab therapy claims denied because claims had two untimed codes appearing on the same claim," says Nancy Beckley with Bloomingdale Consulting Group Inc. in Brandon, Fla.The problem:
"There is no prohibition against billing two untimed codes -- the approved [RAC] issue is for two units of an untimed code," says Beckley.And, "Florida providers are appealing that issue because it represents a misinterpretation of untimed codes by the RACs. An example would be a speech swallowing evaluation and a speech swallowing service on the same claim."
Resource:
Many practices don't realize that CMS offers information on appealing RAC denials.Visit www.cms.gov/transmittals/downloads/R152FM.pdf to read the MLN Matters article that spells out your appeal rights.