Wiki Office visit 99214 Consistently being paid over Medi-Cals Fee schedule

[k.brown@sparc.care]

I am going over a refund page for a insurance company and they are asking for refunds that are payments over $104.75. However medi-cals rate is 37.50. Upon looking at the contract we are supposed to be reimbursed 100% of medi-cals rate. They are not asking for this back and these are claims from over 3 years ago! Please help me figure out why they are paying us this much.

 

[sls314]

I am going over a refund page for a insurance company and they are asking for refunds that are payments over $104.75. However medi-cals rate is 37.50. Upon looking at the contract we are supposed to be reimbursed 100% of medi-cals rate. They are not asking for this back and these are claims from over 3 years ago! Please help me figure out why they are paying us this much.

Were the patients registered correctly? For example, if that payer offers commercial, Medicare, and Medi-Cal plans, could the patient have been commercial reimbursed at the commercial rate? (Or Medicare reimbursed at the Medicare rate.) While you're showing an "overpayment" because the patient bucket in your system is calculating the Medi-Cal rate?

I spent many years working as an analyst where I reviewed underpayments, overpayments, and refund requests. I learned quickly to double-check whether a patient was registered correctly before I invested too much of my time into chasing an over/underpayment that wasn't acccurate.

 

[k.brown@sparc.care]

Were the patients registered correctly? For example, if that payer offers commercial, Medicare, and Medi-Cal plans, could the patient have been commercial reimbursed at the commercial rate? (Or Medicare reimbursed at the Medicare rate.) While you're showing an "overpayment" because the patient bucket in your system is calculating the Medi-Cal rate?

I spent many years working as an analyst where I reviewed underpayments, overpayments, and refund requests. I learned quickly to double-check whether a patient was registered correctly before I invested too much of my time into chasing an over/underpayment that wasn't acccurate.

All other codes on this claim are being reimbursed at the mediCALS rate. I also have ran eligibility on this patient and figured out what kind of insurance they do.