Case Histories Long Term Care Non-Covered Services Not Medically Necessary Medical Coding Error Skilled Care/Insurance Company Sold Long Term Care Non-Covered Services Skilled Care / Insurance Company Sold Not Medically Necessary Medical Coding Error Nursing Home/Long Term Care A client was in a nursing home in a long term care situation receiving skilled nursing care. She had been in the home for several years. Her financial affairs, prior to becoming a CSA client, were handled by her trust officer of a major bank. When CSA received the account, insurance verification was obtained. As a result of the skills and expertise of CSA during benefit verification, CSA noticed a covered benefit that was overlooked by the trust officer and thus, had never been filed. CSA filed the appropriate claims. The end result was additional reimbursement of $30,000 to the client. Benefits Denied/Skilled Care/Insurance Company Sold A client was hospitalized and subsequently placed in a skilled nursing care facility for medicare approved benefits. During this period, the client's insurance company was sold. The new company informed the client that the nursing home benefits were not covered under the contract. The client was prepared to pay the nursing home charges for his now deceased spouse, which amounted to $15,000. CSA stepped in and determined the insurance company was still liable for the coverage because the dates of services began under the old company. A check for $15,000 was issued to the nursing home. Denied Claim/Medical Coding Error - Medically Unnecessary A client was receiving special drug therapy for a cancer condition. The injections were being charged at approximately $1800 per treatment on a monthly basis. Some time after the initial treatment was paid for, Medicare started to deny the claims based on the fact that the drug was not approved for the particular cancer diagnosis. More than a year went by with continued rejections. CSA appealed the claims on the basis that the drug was previously paid for. Medical documentation and justification from the attending physician was obtained and a special code was set up by Medicare to allow the claim to be processed on a manual basis, thereby eliminating the routine rejection that came from the electronic process.  At the time the appeal process was concluded, the client recovered $20,000 in rejected claims. Denied Claim/Not Medically Necessary  - Experimental Mrs. "X" purchased a seat lift chair so she could be lifted out of a sitting position. Without the seat lift, she would not be able to get out of the chair due to her metastatic cancer that had spread to her pelvis and hip. Originally, Medicare denied the claim, indicating the seat lift was not medically necessary. They insisted the wheelchair she used was sufficient. According to Medicare, the seat lift was, in essence, a duplicate piece of equipment. CSA intervened and appealed the claim, yet the claim was rejected again. CSA persisted and appealed to the next level -- a formal Medicare hearing before a hearing officer. CSA argued the seat lift was medically necessary and not duplicate coverage. The seat lift was the only piece of equipment that enabled the patient to properly get up from a sitting position and ambulate. This time, CSA, with input from a registered nurse on staff, reversed the rejection and got Medicare to finally pay the maximum benefits. Benefits Denied/Skilled Care/Insurance Company Sold A client was hospitalized and subsequently placed in a skilled nursing care facility for medicare approved benefits. During this period, the client's insurance company was sold. The new company informed the client that the nursing home benefits were not covered under the contract. The client was prepared to pay the nursing home charges for his now deceased spouse, which amounted to $15,000. CSA stepped in and determined the insurance company was still liable for the coverage because the dates of services began under the old company. A check for $15,000 was issued to the nursing home. Top Top Top Top Top Copyright © 1998 Claims Security of America