Uncomfortable Issue- Need an Answer

[somarco]

If Blue Diamond is correct, and the claim was denied because it is less than 12 months since the last physical, how is the doc supposed to know that (unless of course it was the same doc that administered the last physical)?

 

[kgmom219]

Before you go off the bridge with some of these:

1. Confirm that the procedure/diagnosis codes are correct (Call the doc's office? See what they think. Their EOB probably has more info)
2. Not sure on Medicare, but for U65, STD testing is NOT covered as part of the wellness/preventative exam. When women go in for a well-woman, they don't check for that unless you request it. That's like I saying "I think I might have pneumonia. Can you check?" That's not wellness either.

I'm really hoping this woman uses email and you don't have to call her about STD's.

 

[MatthewC]

If Blue Diamond is correct, and the claim was denied because it is less than 12 months since the last physical, how is the doc supposed to know that (unless of course it was the same doc that administered the last physical)?

CMS instructions are that if the Dr.'s office or Hospital is not certain of the time frame since the last physical or whatever, they are to ask the beneficiary, call other healthcare providers the beneficiary uses or call the Medicare Admin Contractor (MC) and ask them. They can also acccess the HETS system (HIPAA Eligibilty Transaction System) to get that information.

 

[somarco]

CMS instructions are that if the Dr.'s office or Hospital is not certain of the time frame since the last physical or whatever, they are to ask the beneficiary, call other healthcare providers the beneficiary uses or call the Medicare Admin Contractor (MC) and ask them. They can also acccess the HETS system (HIPAA Eligibilty Transaction System) to get that information.

Good to know that all doc offices always know and follow the rules to the letter. I would hate to think some of them might mess up from time to time.

 

[G.Gordon]

I was thinking the same thing. Also, some of these preventive exams are every two years unless a person is in a high risk category.

x2. Have this one happen a few times per year. Even a day or two will kick it out for frequency issues. The high risk is a special code, they can't just file it as a normal visit, learned that one recently.

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I'm really hoping this woman uses email and you don't have to call her about STD's.

I don't know why ya'll are afraid to have these questions. We have open and candid conversations with our clients about anything we need to. Approach it clinically and matter-of-fact and deal with the issues without getting personal. Changes in tone or voice volume can make one "alert" to this is an uncomfortable area. Just keep the same tone and don't reflect anything other than the facts and leave it alone.

 

[MatthewC]

I don't know why ya'll are afraid to have these questions. We have open and candid conversations with our clients about anything we need to. Approach it clinically and matter-of-fact and deal with the issues without getting personal. Changes in tone or voice volume can make one "alert" to this is an uncomfortable area. Just keep the same tone and don't reflect anything other than the facts and leave it alone.

I vote this as best point made of the thread!

 

[bluediamond]

If Blue Diamond is correct, and the claim was denied because it is less than 12 months since the last physical, how is the doc supposed to know that (unless of course it was the same doc that administered the last physical)?

True I see the same doc every year and more if needed. Since the government made electronic records a requirement, he normally (not always) knows when I have seen a specialist and had my diabetic retinal exam. The urology group I see does the electronic records but do not send or hooked up to my doc.

 

[Norwayguy]

True I see the same doc every year and more if needed. Since the government made electronic records a requirement, he normally (not always) knows when I have seen a specialist and had my diabetic retinal exam. The urology group I see does the electronic records but do not send or hooked up to my doc.

Man speed reading these posts makes for interesting reading I was scratching my head over a diabetic rectal exam

 

[goillini52]

Man speed reading these posts makes for interesting reading I was scratching my head over a diabetic rectal exam

I hear you. When scanning the original post I thought the lady was having a routine Anal exam and wanted the Dr. to look for STD's.