Providers to contractors: ‘Get it right’ the first time

Friday, May 16, 2014

YARMOUTH, Maine – HME providers say they’ve had some luck getting Medicare contractors to reopen and overturn denials, but it’s not always easy.

The vast majority (96%) of the 49 respondents to a recent HME Newspoll said they have made attempts to get Medicare contractors to reopen claims denied for technical reasons. Sixty percent said they succeeded and, of those, 80% said their denials were, ultimately, overturned. 

“We have had as many as 16 claims processed incorrectly as recent as April,” said one poll respondent. “These all have to go to a level 2 rep and they have them reopened and reprocessed correctly, but it takes time. This should not be happening nine months after. Fix the glitch and get it right.”

As a result of discussions with the Jurisdiction D DME Advisory Council, CMS has reminded its contractors that their “scope of services” includes reopening cases where claims have been denied due to technical reasons.

Providers who have had some success say you must approach the process methodically.

“I educated the contractor by sending them the written rules (LCD) and then highlighted the areas they were obviously wrong in and showed how our documentation lined up to the letter of the rules,” said one poll respondent.

Despite more responsive and reasonable contractors, the system still has its glitches, as one provider found out while attempting to reverse a claim denied as same/similar.

“To get the same/similar denial processed, we had to go to redetermination,” said the poll respondent. “Well, we had to wait for the refund process before we could appeal the denied item and by that time the initial denial went beyond 120 days. So now they are dismissing our redetermination as past timely filing.”

Going forward, 98% of poll respondents say that, now that they’ve seen others succeed in reopening and overturning claims denied for technical reasons, they’ll try the strategy in the future.

“This whole system is beyond broken,” said Erin Duke, CFO at Duke Medical Equipment in Baytown, Texas. “This shouldn’t be legal to keep providers’ money while the patient keeps equipment and take this long, all over a claim that never should have been denied.”