Denials are wrong to begin with

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Wednesday, April 30, 2003

The recent article appearing in HME News titled, “Bush Plan Would Make It Tougher To Appeal Denials” (see HME Newswire, 17 March 2003) does not mention the fact that many denials given by Medicare’s DMERC are in error to begin with.

I help run a medical billing office that sees a very high percentage of claims denied with an original claim that contains everything needed to pay for a beneficiary’s equipment. Very often, a claim is denied for medical necessity, and a Medical Review is requested. We usually find that Medicare has already been given everything that they say they require in the initial filing of the claim. Medicare will ALMOST ALWAYS DENY this review as well without even looking at the information submitted!

In the appeals process, we have to request a Telephone Appeal so that we can “force” Medicare to listen and then look at the information submitted (that they say they do not have in order to pay the legitimate claim). The process is a complete mockery of the DMERC Suppliers Manual which supposedly tells the provider what is required for a beneficiary to receive his or her benefits. This ridiculous denial process costs Medicare a lot of taxpayer dollars, costs the doctor’s office dollars, costs the provider dollars, and costs the beneficiary time and many headaches.

One would think that a perfectly legitimate claim with all necessary documentation that is filed correctly would not have to go through such a ridiculous time-wasting process. I am quite sure that a good number of the remaining 47% of the 77,388 reviewed claims are actually legitimate claims that should have been paid. We have seen many claims that have all documentation that Medicare has requested deny in the review process because the physician gets fed up with having to prove to Medicare that he or she is prescribing items that are necessary-even though all necessary documentation is on file.

— Tim Parkin is systems manager at R&M Medical Billing
Lymphedema bashing
When is lymphedema pump bashing going to stop? (See HME Newswire item, 10 March 2003) You state the success of the pump in the Stanford Study, then bash it by saying it cannot be used as solo therapy. WRONG. We have numerous clinical studies, showing the efficacy of the pump as solo therapy.

We challenge you to show us one properly controlled, peer-reviewed clinical study showing a lack of effectiveness of the lymphedema pump used as solo therapy. Complications, as in any other medical device, can only be caused by improper usage.

— Robert G. Freidenrich is CEO of Bio Compression Systems

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