Wiki Medicare Denial

[karriedemas@yahoo.com]

I need some help - a patient had surgery Jan 2016 and Aetna paid the claim in full - Dec 2016, Aetna retracted their payment stating patient had another insurance as primary - We left messages for the patient and billed the patient and they called us back in Jan 2017 with their correct insurance - Medicare. I billed Medicare and received a denial for Timely filing - I appealed the claim with documentation stating the wrong insurance was billed and it was denied because it was filed more than a year after the procedure was done. What should my next step be?

 

[erjones147]

Go through the Medicare appeals process. Your MAC should have forms available online, and the process (at least for the first 2 levels of appeal) is easier than you think

 

[ellzeycoding]

You can file an extenuating circumstance appeal showing your initial claim WAS filed timely and that the patient didn't provide accurate and timely information about their coverage.

You can file several levels of appeals.

If these fail, and you have the documentation to PROVE that they didn't provide you with all of their insurance information at the time of service, then you should bill the patient since they misrepresented their insurance coverage and didn't provide accurate information in order for you ro be paid for your services. Further reimbursement to them would be between them and their insurances. But make sure you can prove they didn't completely disclose their coverage.