Washington, DC (PRWEB) July 30, 2015
WellSpan Health in York, Pa., has found itself in a fight with its Medicare administrative contractor (MAC) over submitted claims for bariatric surgery that, despite complying with national and local coverage determinations, has been rejected. Calling it a challenge to program integrity, Becky Dennis, a nurse auditor at WellSpan Health, tells Atlantic Information Services’ (AIS) Report on Medicare Compliance (RMC) in its July 27 issue that the claims are being “returned to provider” — RTP’d —which means the claims can be fixed and resubmitted for payment, but can’t be appealed through the usual five-level administrative appeals process. She acknowledges that WellSpan made some coding errors, but says that the MAC is using antiquated Medicare policy. And for bariatric surgeries, a lot of money is at stake — Medicare pays hospitals almost $11,000 for a particular type of bariatric surgery, she says.
The language in the MAC’s local coverage determination (LCD) seems to contradict itself, Dennis tells RMC. The LCD states that “surgical treatment for primary obesity is not a covered Medicare service,” then says, “CMS national policy dictates that surgery for morbid obesity is covered for Medicare beneficiaries who have all of the following: a body mass index of 35 or higher, at least one comorbidity related to obesity and previous unsuccessful medical treatment for obesity.” It also agrees to cover “Laparoscopic Sleeve Gastrectomy as a stand-alone procedure.” In one case cited by Dennis, a patient met all of the above criteria — she was considered “super morbidly obese,” had three comorbid conditions and received obesity treatment — and underwent a laparoscopic sleeve gastrectomy, the claim for which the MAC denied. “I am getting 20 different reasons why they processed the claim that way,” Dennis says, adding that “they are quoting their own policies incorrectly,” she says.
After working and re-working on the account for almost a year, Dennis says the audit team realized the procedure code the hospital submitted was wrong, but, “notwithstanding the errors on our part, the MAC has made the process of determining their reasons for rejection somewhat of a loser’s game,” she contends.
Visit http://aishealth.com/archive/rmc072715-01 to read the article in its entirety, including Dennis’s suggestions for fighting for reimbursement and advice from attorney Andy Ruskin with Morgan Lewis.
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