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July 2016 Client Newsletter

Verifying Eligibility for a Service or Product,
or Obtaining Authorization
Verifying eligibility or obtaining an Authorization number has been a standard procedure for many years.  Unfortunately, standardizing the process is not always complete and usable for appeals.  It is easy to create a standard form. 
When your staff calls an insurer, they should note:
  • The date and time of the call.
  • The name of the customer service representative.
  • Verify coverage dates which have been paid.
  • CPT/HCPCS codes covered.
  • Whether the patient's diagnosis code(s) are covered.
  • The allowed amount of the payment.
  • Amount of deductible and/or coinsurance/copayment, if any, and
  • at the end of the conversation, the reference number.
The call can go something like this: 
"I am calling to find out if CPT or HCPCS Code, product or service description are covered for Dr. X, a specialist, for diagnosis XXX & YYY?  Please verify coverage dates.  If it is covered, then ask how much should be paid, plus the deductible and coinsurance/co-payment amounts for this patient."
Language "Interpreter" Scam
Just heard of a scam and wanted to share it with you.  Patient brought a family friend to an appointment and wanted the family friend to be their "family interpreter."  Often they will agree to a rate lower than normal - but in reality the patient already speaks English and this is just an opportunity to earn money for the "family friend."

While providers are required to provider interpreter services, you may want to stick to other sources to avoid such a scam unless you know more about the patient. 

GAO report: Medicare Appeals Backlog Getting Worse
On June 9, the Government Accountability Office (GAO) released a report concluding that the Medicare appeals backlog continues to grow at a rate that outpaces the adjudication process and will likely persist without a major structural overhaul. The report cited enormous increases in Medicare appeals from fiscal years 2010 to 2014, including a 103 percent jump for Part B claims and more than 2,000 percent jump for Part A hospital claims.

In addition, GAO found that the number of appeals decisions issued after the general 90-day statutory time frame had increased and that Health and Human Services' (HHS') failure to capture more specific appeals data inhibited the agency's ability to effectively identify the reasons behind the backlog and develop a meaningful solution.

Heroin Overdose
Be advised that we have now had a written denial by Horizon on behalf of a "Home Plan" that says "service related to heroin overdose are policy exclusion." 


DME MAC A Transition July 1st
As mentioned before, the DME MAC A has transition from NHIS to Noridian on July 1st.  Cape Medical Billing has been thru this numerous times before and we do not expect any issues.   
2016 Client Newsletter Archive