Quote:
Originally Posted by golfing eagles
Not even close to how it works for MA plans and TVH
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Actually, it's pretty close. There's a professional (doctor) and technical (facility) component to billing in many cases (some have prof or tech only). The doctor makes the diagnosis and determines the course of care, consult notes, treatment plan, etc. that are used to obtain the prior authorization, when needed. For there to be this much money involved this would almost have to be a systemic problem. On the other hand, if this is a coding dispute, this could be a greedy auditor trying to get a percentage of the recovered billing. Before I retired, "Medicare" claimed we improperly used a treatment technique known as IMRT on nearly all our cases, so we had a RAC audit, and they wanted to claw back virtually all the money. We appealed all the cases and only lost one that was a close call on medical necessity. The key is having 100% of the supporting documentation before ever submitting a charge. We had weekly charge reviews where staff looked at every charge to make sure it fit and there was supporting documentation.