Outpatient Surgery Magazine

Battle Post-op Pain Without Opioids - April 2016 - Subscribe to Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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Page 33 of 122

Check the validity of the denial It's not uncommon for insurance companies to use creative, yet inappro- priate, tactics to enhance their profit margins. Even though providers will sometimes dispute or appeal overpayment allegations, payers may continue to move forward with the process, ignoring their obligations and offsetting the disputed amount on future claims until the refund is granted. To fight back, first evaluate the validity of a benefit denial or refund demand. If you can show that the insurer made the error that led to the alleged overpayment or if there was, in fact, no overpayment at all, you'll have more success during the appeal process. Never just assume a payer's findings and statements are accurate. To judge the validity of the denial, start by asking a few questions about the refund demand and claim in question, including: • Did the facility initially receive the entire payment for all services rendered, including for implants, splints and radiology? • Were there any services or items that were underpaid or unpaid? • If a service was unpaid due to an error, who made the initial error? • Are the insurer's billing allegations factual? • Do you suspect that the payer violated any compliance require- ments, like appeals or other notification requirements, in issuing the refund demand or denial? An invalid request? If you find yourself suspecting that the refund request isn't valid, it's time to take action. You're required to refund overpayments only when there is clear evidence of "unjust enrichment" of the claim or for services not rendered. Even if you've been overpaid, it's crucial to determine where the error stemmed from. If the insurer mistakenly paid the claim, don't take ownership of it. Appeal the refund request 3 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • A P R I L 2 0 1 6 Coding & Billing CB

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