Wiki Buried under recoups!

[jemfulke]

Hi all,
I just replaced someone who was in over his head. It's a mess. My issue is that there was a name and address change to the clinic 5 years ago. The current scenario is this... All of our payer contracts are listed with the old provider name and address. Someone did demographic change forms, but never renegotiated or updated contracts with anyone, so our current clinic name is showing in Network, but the contracts and fee schedules are all registered to the old clinic name. EFT, bank account, everything else has been updated to new name and address as well.

Can I submit corrected claims with the former clinic name as the pay to provider (one the contracts reflect), and the current clinic name as the service facility since it is in network? They both have the same NPI and tax id. I have documentation of the name change with the Secretary of State of the former name to current. I am working on getting all our contracts and CMS updated to the current name and address, however, I need to continue to work these recoups and see what I can get done, so I am trying to find a way I can continue to submit claims and be confident the money will stay.

 

[thomas7331]

It's rather difficult from the brief summary you've given here to really understand what's going on with your claims. Your situation sounds a bit complicated and I'm not sure it can be easily answered on a forum where we don't have access to your contracts and more details about how your clinic has been billing - we're coders and billers here, not contract lawyers or accountants. The short answer, from a coding and billing perspective, is that you can submit a corrected claim if you know that the original claim was filed with incorrect information and needs to be replaced with correct information. So, for example, if an old claim was filed with an incorrect location, then that should certainly be corrected.

But as to whether or not your clinic can retroactively bill claims under a different clinic name for purposes of having the claim paid under terms of a different contract, that is more of a legal question and I'd recommend you run that by your clinic's legal and/or finance department and get their assistance in making a plan to rebill claims, if in fact they indicate to you that it is appropriate. Without looking at your clinic's contracts and comparing the terms with how the claims were originally billed and paid, I don't think anyone can give you a really reliable answer to this question.

 

[jkyles]

Hi there, It's tough to inherit someone else's problems. However, if you've been billing Medicare under incorrect enrollment information I highly recommend working with a consultant who specializes in enrollment to get this sorted out.

 

[jemfulke]

Thanks for the replies everyone. I was in a panic, but I have a better handle now. I have now confirmed, the payer contracts are all in the current name and correct; and have been billed properly. Somewhere along the way, something was dropped with updating the CMS/Pecos system. When I had posted this, I had already spoken to them and made them aware, submitted proper paperwork, etc. The issue is that the crossover claims were being sent to the secondary with the old name even though we were initiating them with the correct info, so those commercial payers were recouping for out of network. I have spoken to them, and am submitting corrected claims with the current name/contract info that matches. Fortunately, our specialty is not reimbursed much by Medicare, so there is not much of an issue there. We are fine to have those amounts recouped. The bigger issue was these secondary payers and commercial payers who received the incorrect secondary info. I got that system all cleaned up and am just doing claims directly on payer sites for a while. Now it's just a waiting game for the CMS paperwork to process, then I can start utilizing the crossover claim/clearinghouse software again.

Whew, this guy was in over his head. It's so tough when you see a good hearted group of doctors who want to better healthcare and do right by everyone, get in these messes, because someone oversells their qualifications. It's a tough time to be in private practice. BTW, he had an AMBA billers certification. Last I heard, another doc who was using him is getting an attorney. I'm just grateful it's manageable and I can see the horizon now.