Medical Claims Appeals
A failure to receive or keep reimbursement, if a consistent enough issue, will threaten the viability of any medical service. For the comprehensive wound care center, reimbursement shortcomings can be particularly problematic if hyperbaric oxygen (HBO) therapy changes are involved. This is because average per-patient charges are high when compared to other diagnostic and therapeutic service rendered at the center.
Payment problems can result from several circumstances. It may be that the insurer’s determination of what is provided and charged for is not medically necessary. This may be the result of documentation failures or coding errors. It may be a 'systems error', either within the hospital or by the insurer. It may also be an incorrect insurer determination. Whatever the circumstances, NBS can be instrumental in repairing problems on the provider side and gaining reimbursement where Medicare and commercial insurance companies are thought to be in error.
For more than three decades, NBS has been actively involved in medical claims billing, reimbursement and the overturning of denials. We have been successful in a very high percentage of cases, particularly those related to provision of HBO therapy. In particular, we have been successful in every Medicare case that was brought before an Administrative Law Judge.
Throughout this period, NBS has served in an advisory capacity on behalf of Medicare and leading commercial purchasers of health care. We have helped them clarify medically necessary policy language, better appreciate supportive science, and better match diagnosis codes to approved indications. All of this provides unique insights into ways we can help providers and hospitals.