Our Thoughts on Best Practices

A 56-year-old woman underwent surgery for a breast abscess. The plan would have paid $4,860. To avoid an NCCI edit, the provider submitted two claims instead of one, hoping that the plan wouldn’t catch the split bill. After reviewing the records, we denied both claims as neither code was supported.

A 20-year-old female presented to the ER with abdominal pain. Her health plan would have paid $11,936, but after reviewing records, Nokomis found that the listed provider was not the interpreting provider and had an inappropriate charge for IV fluids ($3,567). Ultimately, the health plan saved $7,566 after our review.

A 27-year-old male was treated in the emergency department for a laceration to his leg. His provider was ready to pay the claim, but Nokomis investigated the cause of the accident and discovered the injury happened on the job. The claim was denied and referred to the workers’ comp career for payment, saving the plan…

A 37-year-old woman presented at a free standing ER at 2:53am for treatment of a possible UTI which was evaluated with a dipstick urinalysis and treated with an oral medication. The patient was then discharged, 24 minutes later, at 3:17am. The plan would have paid $6,340. Nokomis obtained records and found that the provider billed…

We will always go to bat for the patient. Our goal is not to deny care, but to deny inaccurate claims. In fact, only 99.3% of our denials are refiled or appealed, because we take an intelligent and holistic approach to reviewing claims as accurately as possible. In this week’s claim of the week, a…

A 58-year-old woman presented to a weight loss clinic for a medical weight loss consult. The clinic submitted four codes-two of which were supported, plus a lung function test and an unlisted diagnostic x-ray code. Unlisted codes often just get paid by health plans, but should always be carefully reviewed. Our expert team of coders…

A patient presented with a lesion on their neck. After evaluation and treatment, the provider billed three codes, of which her health plan would have paid $2,186. The claim looked fine at face value, but when Nokomis received records, our team discovered that none of these charges were supported. While the patient did receive services,…

A patient had an injection in their ankle joint for pain management. Following the injection, the provider charged $16,281, of which the health plan would have paid $8,141. These charges were not supported. Nokomis denied most claim lines, and reduced the bill to $75 – saving the health plan $8,066.

A patient received anesthesia for an upper GI endoscopy, and their health plan would have paid $1,499. However, the provider charged for emergency anesthesia, which was not supported by the documentation. Ultimately our review reduced the bill for our client to $333 total, saving them $1,166.

A patient presented at a free standing ER for upper respiratory symptoms and tachycardia. The provider charged a level 4 E&M visit, a critical care charge, and interpretation charges for an EKG and a chest CT. After our team reviewed the records, we found that the critical care charge was not supported, and there was…