Inaccurate Claim Denials Overturned

VGM effort to collect inappropriate denials for OMHA meeting pays off for providers.

A VGM Group effort to collect documentation on claims that were inaccurately or inappropriately denied that was presented at a meting with CMS’s Office of Medicare Hearings and Appeals (OMHA) has paid off in an unexpected way: many of the denials were overturned.

The claims data was collected for February’s OMHA Appellant Forum in Washington, D.C. concerning OMHA’s decision to delay assigning administrative law judges to audit appeals by two years. The meeting afforded VGM members the opportunity to question Chief Judge Nancy Griswold about the tumultuous DME audit process.

Prior to the event, Peggy Walker Peggy Walker, RN, Billing & Reimbursement Advisor with VGM’s US Rehab Division, requested that providers send her examples of second-level denials that resulted from clerical errors or obvious oversights. Walker prepared the documents in a packet she submitted along with her testimony that day at the forum.

CMS sent the examples to C2C Solutions, the second level contractor that had previously denied the claims.

Of the claims submitted, 70 percent of them were overturned fully or partially in favor of providers, indicating that the original denials were made in error.

C2C replied directly to Walker, and she will notify providers of the results.

“C2C Solutions was willing to look over the denials that were made in error,” Walker said.“The errors were technical errors that were reviewed inappropriately by the first two levels of appeals.”

A VGM statement advised that any  provider that has a claim denied because of an issue that was clearly a technical mistake is encouraged submit the claim to Walker for review and possible reopening. Those providers should link to the form here and once completed, fax to Walker at (877) 907-3862.

About the Author

David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on Twitter at @postacutenews.

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