Hi All,
I am wondering if any of you have come across this issue and if this is a systematic problem with United Healthcare. Similar to the prior authorization issue mentioned in a previous post.
We recently received a refund request from UnitedHealthcare for a prosthesis we provided for a patient on a Medicare covered Part A skilled nursing stay,which in this case, being that it was a United Healthcare Medicare Advantage plan, it was under the United Healthcare Medicare covered stay. The letter said that since the patient was on a Medicare covered stay the bill for this DME item should be billed to the nursing home.
Medicare rules clearly state that most prosthetics are excluded from SNF Consolidated billing and a list is available on the CMS website. The codes we billed, with the exception of the sock codes, are clearly on that list and we appealed the denial with that data included. We provided the rule number and the link to the list of excluded items.
Today we received a new letter stating that the denial is being upheld because according to the Medicare claims manual chapter 6 these items should not be billable to Medicare plans when the patient is in a SNF. They are trying to say that the nursing home is responsible.
We will be continuing to fight this but I’m wondering if any of you have received such a denial and what you found successful, or not…
Best,
Shlomo
Shlomo Heifetz
Director of Operations
Presque Isle Medical Technologies
