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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How & Why We Negotiate Medical Claims

Nokomis Health | Claim Negotiations

It is an all too common occurrence: a motorist is seriously injured in a car accident and requires emergent treatment. According to the National Safety Council, nearly 6,300 people sustain serious injuries every day in the U.S. due to motor vehicle accidents1. Most of these people are immediately transported to the nearest hospital for care. Checking to see whether the doctor or hospital is “in-network” is a secondary concern. Everyone’s priority is saving the patient’s life and restoring function to the injured body.

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The Power of the 59 Modifier

Nokomis Health | Modifier 59

Do you know how much power there is in a single two-digit number? Most payors and health plans don’t realize the impact that the 59 modifier can have on claim costs. Adding this simple modifier to a CPT code allows that code to bypass several code edits, resulting in erroneous and often incorrect payments. Providers have learned that the way to avoid denials is to append a 59 modifier to many codes. The problem is that in many instances, the modifier is not appropriate.

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