Our Thoughts on Best Practices

A 52-year-old woman underwent gallbladder surgery. The plan would have paid $12,090; however, after reviewing records, we discovered that the documentation did not support the codes, ultimately saving $5,270.

A 43-year-old woman underwent back surgery to implant a spinal cord stimulator to alleviate her back pain. The plan would have paid $17,160, but further investigation uncovered that the documentation did not support the items in the claim. We recommended denying this claim, saving the plan $17,160.

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…