DESCRIPTION OF THE ISSUE
Whenever we use Psychiatric related diagnosis
as primary one on a claim, this will cause a payment reduction from Medicare.
The reduction has covered by some of the commercial secondary Insurances and if
the patient does not have such, we could not bill the balance amount fully to
the patient responsibility, we can only bill the 20% of the Medicare balance to
patient not the reduced amount.
CONCEPT
If a patient treated
for an Office/ Hospital visit based on the Psychiatric problem and if the
patient needs specialty treatment, this would cause reduction on payment.
SOLUTION
Once we receive a claim with primary diagnosis
related to Psychiatric (ICD Starts from the numeric 3) we need to check with
Client Office whether there is any alternative primary Diagnosis. If reduction
done by Medicare then we should correct primary ICD through Medicare IVR
Telephone Clerical Reopening option
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