Schemes, Errors & Scams – How Uncommon Claim Review Findings Lead to Savings

Nokomis Health | Stories from the Front Line

Nokomis Health’s coding team was reviewing a client’s out of network laboratory and a batch of genetic testing claims raised some questions. The claims appeared to be legitimate – the CPT code was valid, the diagnosis code supported the charge, the NPI and TIN were correct – but the charges were very high for the code and it was unusual for the code to stand alone. We obtained records on several claims and found that the lab was simply performing a quality assurance function, they were not performing a covered service.

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Building a Better Claim Review Company

Nokomis Health | Founder Rich Henriksen

INTERVIEW WITH FOUNDER RICH HENRIKSEN

How did you get started in the claims field? What was your career path prior to Nokomis Health?
I graduated from Luther College in Decorah, Iowa with a biology degree and then received my master’s degree in hospital administration from The University of Iowa. Scott Anderson, the CEO of North Memorial Medical Center in Robbinsdale, Minnesota, was an alumnus of my graduate program and each year he took on an administrative fellow from my program. He selected me to come to his hospital, so I moved to Minneapolis and ended up staying at North Memorial for 7 years. I was originally deployed to the Finance department, where I automated the hospital’s budget process. I stayed in Finance for my entire tenure at North, ultimately becoming the director of managed care. It was at this time that I really learned about coding, reimbursement, contracting, contract modeling, and data analysis. Pat Boran, the CFO, was a super boss and mentor. I learned a great deal from him.

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Medical Coding 101 – Insights, Challenges and Standard Practices

Nokomis Health | Medical Coding 101

Q&A WITH NOKOMIS HEALTH DIRECTOR OF CODING ANNE KARL

What are CPT Codes?
As you may know, every procedure code on a claim is tied into a dollar amount. So if a coder miscodes something, the provider could be paid for a code that isn’t supported by the documentation or the clinic may be losing reimbursement that is rightly due to them. Miscoding is typically a result of coders lacking education and not knowing how to code properly or they may be trying to game the system. That’s why insurance companies need a claim review partner. We can look for trends that we see in the claims and set an edit to manually review those claims or automatically deny them. Just because there is a CPT code doesn’t mean that you can use that code for reimbursement or use it for reimbursement in combination with other codes.

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How Do You Become an Expert Medical Coder?

Nokomis Health | Director of Coding Anne Karl

INTERVIEW WITH DIRECTOR OF CODING ANNE KARL

How did you get into coding?
My father was a family practice physician and I’ve always been drawn to that world. When I came out of school the traditional job for an RHIA (Registered Health Information Administrator) was to be the Director of Medical Records in a hospital setting, but that didn’t really interest me. The physician setting is much more fast-paced and I’ve spent a majority of my career in that area. I always had my heart in it – making sure the providers were paid fairly for their services. Payment starts with the documentation of the provider and the codes assigned. Poor documentation and/or coding can really hurt the reimbursement to a provider. After working in some very non-traditional jobs, I found that coding was really my passion.

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