Wiki Non Supporting Diagnosis provided after denial received

[cfisher1]

Is there a compliance requirement that states a denied claim denied due to medical necessity must be resubmitted to insurance if a physician provides another non-supporting diagnosis?

Also, is there a compliance issue related to reaching out to a physician to ask if there is additional information after a claim receives a denial for medical necessity? This correspondence does not ask physician for specific dx information. It is general correspondence.

 

[thomas7331]

Some of this would depend on the entity who is exchanging this information and corresponding with the physician. Are you speaking of the insurance company, the patient, the physician's billing company? If you can provide a little more context, it could be easier to answer the questions.

 

[cfisher1]

Some of this would depend on the entity who is exchanging this information and corresponding with the physician. Are you speaking of the insurance company, the patient, the physician's billing company? If you can provide a little more context, it could be easier to answer the questions.

We are a lab billing for the testing requested by the ordering physician. We would be sending a more information letter request to the physician to ensure that all documentation related to this order was complete. Many times the physician leaves out information or missing information related to the lab order.

 

[thomas7331]

I don't know of any regulation that would require you to resubmit the claim if you know in advance that the diagnosis is not going to support payment, but it would probably not hurt to submit it anyway so that the payer has the most accurate information on file should there be any questions.

There isn't a compliance issue with contacting the physician for more accurate diagnostic information if what you have doesn't support payment and you do not have access to the physician's records. Per CMS guidelines "A laboratory or other provider must report on a claim for Medicare payment the diagnostic code(s) furnished by the ordering physician. In the absence of such coding information, the laboratory or other provider may determine the appropriate diagnostic code based on the ordering physician’s narrative diagnostic statement or seek diagnostic information from the ordering physician/practitioner. However, a laboratory or other provider may not report on a claim for Medicare payment a diagnosis code in the absence of physician-supplied diagnostic information supporting such code." It's a routine practice for labs to contact physicians when this information is needed and you should keep written records of those communications as an audit trail. Of course, any correspondence you send should be done in line with your company's HIPAA privacy policies in order to provide adequate protection to the patient's information.