Wiki Managed care denials

[MILLINRP]

How many are seeing denials from Medicare Managed Care (also Medicaid) for the payer not recognizing our provider specialties. I work in Cardiology and we have a growing number of denial stating the patient is not New and to rebill as an established patient, service bundled, etc. They are clearly new patients for that particular specialty and will not overturn denials even with an appeal. I was wondering what others are doing to fight these denials. We have already appealed stating different provider specialty and different diagnosis.

 

[CBLENNIE]

Have you checked with your various carriers to confirm what taxonomy code they have your cardiologists credentialed with? I work for an insurance company, and we see a lot of providers credentialing paperwork submitted with 2 taxonomy codes, internal medicine and some other specialty such as cardiology. In general, we will setup the provider in our system with the primary taxonomy code that is listed first on the paperwork. Our claims system then adjudicates claims based on the primary taxonomy code, so if your cardiologist happened to be loaded into the claims system with internal medicine taxonomy code, then we are going to process claims for the provider as if they are practicing as an internal medicine provider.

For us the diagnosis wouldn't matter, it all comes down to how the provider was setup in the system when we credentialed them.