CHALLENGE:
Conditional Payment Notice submitted to Tower for potential dispute. Charges identified by the CRC included multiple Conditional hospital stays, ER visits and surgeries, as well as treatment by unauthorized treating physicians as per the state’s worker’s compensation statute. State of jurisdiction was California. Accepted body part was lumbar spine. Total conditional payment exposure was $71,349.
SOLUTION:
Tower’s CP specialist first confirmed date of injury, accepted body parts and the approved ICD10 codes as reported via Section 111 ORM for the assigned claimant. We then requested and obtained all medical records for dates of service identified by the CRC for recovery. Records reviewed include 2 hospital stays, psych visits, surgical and post-surgical follow up visits. Each medical record was compared against indicated diagnosis codes for the lumbar spine. During the review, Tower obtained documentation confirming that hospital services occurring 1/5/15 thru 1/11/15 were related to a cardiac condition and bypass surgery. Additional services disputed included charges for psych visits unrelated to the workers’ compensation injury. Tower provided documentation as follows: “Patient was advised to discuss pain management issues with Dr. XXXX who is her workers’ compensation primary physician.” Also, disputed was a hospital stay from 8/25/14 thru 9/4/14 for respiratory failure and possible drug overdose.
RESULTS: 100% REDUCTION OF CONDITIONAL PAYMENT
With client approval, Tower submitted the Conditional Payment Dispute Package to the CRC noting that as per the documented evidence provided, we are requesting that the full amount of the Conditional Payment Notice ($71,349) be removed. In its review of the package, the CRC concurred with Tower’s rationale for exclusion of the services for which recovery was requested and issued a ‘Valid Dispute -No Interest’ letter to confirm that the services were appropriately paid by Medicare. Total savings= $71,349.
