Our Thoughts on Best Practices

A 34-year-old male received intensive outpatient services for addiction. His plan would have paid $16,212, but after reviewing records, Nokomis found that the patient didn’t receive the minimum hours of service for what the provider billed. We ultimately saved the plan the entire $16,212.

A provider submitted a claim for 3 days of continuous EEGs. The plan would have paid $100,000, but after reviewing records, Nokomis found that the provider finalized records only after submitting the claim and receiving the request for records. Documentation cannot be finalized after claim submission or after records have been requested. We ultimately saved…

A DME provider submitted a claim for an external defibrillator. The plan would have paid $4,050, but after reviewing records, Nokomis found that there was no proof of delivery to home or that the member ever received the item. We ultimately saved the plan the entire $4,050.

A 50-year-old male received dialysis for a month and the provider submitted a claim for dialysis, supplies, and administration of drugs. His plan would have paid $184,258, but after reviewing records, Nokomis found that while the dialysis procedure itself was supported, they charged for numerous lab tests without a valid order and an infusion of…

A diabetic patient underwent outpatient surgery for treatment of a foot wound. The plan would have paid $23,629, but after reviewing records, Nokomis found that the codes billed by the surgery center were not supported and it billed for supplies that should not have been separately charged. We saved the plan $13,445.

A DME provider billed for the rental use of a pneumatic compression device. The plan would have paid $9,689, but after reviewing records, Nokomis found that, based on the patient’s condition, the use of the equipment was not compliant with the plan’s coverage. We saved the plan the entire $9,689.

A 34-year-old male presented for an EEG. His plan would have paid $1,462, but after reviewing records, Nokomis denied the claim because documentation did not support that an EEG was performed. We saved the plan the entire $1,462.

A lab submitted a claim for a 57-year-old-patient with UTI symptoms. The plan would have paid $667, but after reviewing records, Nokomis found that the orders were invalid, and ultimately saved the plan the entire $667.

A 17-year-old female had back surgery. Her provider submitted a claim for $42,928 for neuromonitoring. The claim was completely inaccurately coded and billed. We ultimately saved the plan the entire $42,928. It’s important to note that this recommendation was not appealed!

A lab test was performed for a genetic screening of prostate cancer. The plan would have paid $2,233, but after reviewing records, Nokomis denied this because the plan had a policy on when that’s appropriate to use, and the patient did not meet the criteria. We ultimately saved the plan the entire $2,233. Oftentimes, you…