Wiki Acute fracture while in hospice

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cpccpma

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:confused:Happy Friday fellow coders! This is a new one for me so I wanted to put it out there for input.....thanks in advance!

Patient is covered under secure horizons-recently went into hospice (which means anything hospice related will be paid by Medicare direct and not sec horizons). Patient fell out of bed while in hospice went to the hospital and had surgery. Now since this falls out of the hospice treatment secure horizons would need to pay for the consult and surgery performed right? The claim is denied by sec horizons stating that this is hospice related and should be billed as such.....but medicare will deny since this is an acute injury.....or am I way off base
 
It was and the strange thing is my AR rep appealed the claim and with the help of our provider rep (I know...provider rep help...can you believe it???) the denial was overturned and paid. Now johnson and roundtree wants a refund and my rep has talked to customer service at the insurance co.....they are saying too bad should have been paid under hospice. Ummmm....no. I mean no disrespect but sometimes those employed at the insurance companies are not always the brightest bulbs in the pack....know what I mean? Any ideas on how to "help" them see the error of their ways? :)
 
I completely understand your frustration. Many times I find myself speaking in very elementary terms when in a conversation with the insurance reps. How do they justify this injury in relations to the hospice condition?

Often, I submit CMS citations to overturn denials. Do you think it would help if you referred them to section 50 of Chapter 11?

http://www2.cms.gov/manuals/downloads/clm104c11.pdf
 
That is perfect....thanks for the link! I'm gonna add to our ammo and maybe draw some pictures too! :) Thanks again and have a wonderful weekend!
 
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