A client was in a nursing home in a long term care situation receiving skilled
nursing care. She had been in the home for several years. Her financial affairs, prior to
becoming a CSA client, were handled by her trust officer of a major bank. When CSA
received the account, insurance verification was obtained. As a result of the skills and
expertise of CSA during benefit verification, CSA noticed a covered benefit that was
overlooked by the trust officer and thus, had never been filed. CSA filed the appropriate
claims. The end result was additional reimbursement of $30,000 to the client.
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A client was hospitalized and subsequently placed in a skilled nursing care
facility for medicare approved benefits. During this period, the client's insurance
company was sold. The new company informed the client that the nursing home benefits were
not covered under the contract. The client was prepared to pay the nursing home charges
for his now deceased spouse, which amounted to $15,000. CSA stepped in and determined the
insurance company was still liable for the coverage because the dates of services began
under the old company. A check for $15,000 was issued to the nursing home.
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A client was hospitalized by way of the emergency room and intensive care unit.
The client had taken a drug to relieve himself of a food allergic reaction. Upon review of
the claims submitted by the providers in the emergency room and the hospital, the
insurance company denied the claim stating: Drugs taken with the willful intent to harm
one-self was not a covered service. CSA questioned the denial and requested a detailed
review of the patient's medical records. CSA held several discussions with the patient's
providers and insurance company. After the investigation, the insurance company reversed
its decision. They indicated the admission should have been covered and the client, did in
fact, receive an adverse drug reaction, as opposed to a willful drug overdose. The amount
in question was approximately $10,000.
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Mrs. "X" purchased a seat lift chair so she could be lifted out of a
sitting position. Without the seat lift, she would not be able to get out of the chair due
to her metastatic cancer that had spread to her pelvis and hip. Originally, Medicare
denied the claim, indicating the seat lift was not medically necessary. They insisted the
wheelchair she used was sufficient. According to Medicare, the seat lift was, in essence,
a duplicate piece of equipment. CSA intervened and appealed the claim, yet the claim was
rejected again. CSA persisted and appealed to the next level-- a formal Medicare hearing
before a hearing officer. CSA argued the seat lift was medically necessary and not
duplicate coverage. The seat lift was the only piece of equipment that enabled the patient
to properly get up from a sitting position and ambulate. This time, CSA, with input from a
registered nurse on staff, reversed the rejection and got Medicare to finally pay the
maximum benefits.
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A client was receiving special drug therapy for a cancer condition. The injections
were being charged at approximately $1800 per treatment on a monthly basis. Some time
after the initial treatment was paid for, Medicare started to deny the claims based on the
fact that the drug was not approved for the particular cancer diagnosis. More than a year
went by with continued rejections. CSA appealed the claims on the basis that the drug was
previously paid for. Medical documentation and justification from the attending physician
was obtained and a special code was set up by Medicare to allow the claim to be processed
on a manual basis, thereby eliminating the routine rejection that came from the electronic
process. At the time the appeal process was concluded, the client recovered $20,000 in
rejected claims.
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