Filing Denials

SHobbs

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We have heard both answers to this but would like any feedback... Are we supposed to file a claim to any insurance company that we know is not covered and will be denied.

a couple of examples:
filing visits with dental dx to Medicare?
filing sick visits to Medicaid when the patient is only covered under Womens Health?

Thanks.
 

btadlock1

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Lubbock, TX
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We have heard both answers to this but would like any feedback... Are we supposed to file a claim to any insurance company that we know is not covered and will be denied.

a couple of examples:
filing visits with dental dx to Medicare?
filing sick visits to Medicaid when the patient is only covered under Womens Health?

Thanks.
Medicare - ABN prior to rendering service, then append the appropriate modifier (GA, GX, GY, or GZ - in the case of dental, I'd say probably GY)
Medicaid - I'd probably collect payment up front, if possible. You should really check your individual state laws on that sort of stuff, though - you may not have a right to bill the patient, in certain situations, but it's impossible to predict, without knowing what state you're in. It probably wouldn't hurt to get them to sign a form similar to an ABN, just to be safe (although, ABN's are only really for Medicare patients...it's better to let them know ahead of time, anytime you think they'll end up being responsible for a bill. It saves you trouble later...)

;)
 
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I'm glad that you mentioned ABN's Brandi. My facility does a lot of screening tests (they are college students) and we are trying to work out the process and flow for issuing an ABN/waiver form. We of course do not bill Medicare just commercial insurance carries. Who initiates the ABN/Waiver to the patient, the front desk staff, or the nurses? Our issue is that the front desk staff is not aware of what the services will be before getting to the back. Any help you can provide would be awesome.

Thanks.
 

btadlock1

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I'm glad that you mentioned ABN's Brandi. My facility does a lot of screening tests (they are college students) and we are trying to work out the process and flow for issuing an ABN/waiver form. We of course do not bill Medicare just commercial insurance carries. Who initiates the ABN/Waiver to the patient, the front desk staff, or the nurses? Our issue is that the front desk staff is not aware of what the services will be before getting to the back. Any help you can provide would be awesome.

Thanks.
Well, if you don't file to Medicare, it's technically not required; however, it is a good practice, especially for cosmetic procedures, or any other time you'd expect to receive a denial.
In my opinion, waivers would best be issued by the nursing staff, since the discussion about the service would likely be made in the exam room, and not the waiting room. The front office staff could be responsible if the procedure was scheduled in advance, but I wouldn't place all reliance on them to handle it, since they're unaware of the medical decisions that might be made, later on.
Remember that with ABN's, in particular, you can't have the patient sign a 'blanket' waiver - it has to be specifically tailored to the patient and procedure in question, to count. Hope that helps! ;)
 
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