Mount Carmel Medical Group Worthington

Received patient correspondence and have conducted appropriate research Upon discussing reseach findings with patient, advised patient to contact payor to request appeal and their reason codes in totality Requested patient to follow up with our office upon receiving payor response Thank you [redacted]

I wanted to let you know that I heard back from *** regarding the appeal. They are not honoring the claim because of the treatment code the physician submitted. I have another call into the Mt Carmel/Caren Way office. I cannot believe I am still going round and round with them,
Let me know if you know anything else I can do at this point. I don't feel that I should pay for services not rendered
Thanks,
*** ***

I was not aware of the diagnosis prior to receiving the rejected claim by the insurance I simply was getting my ear checked for a suspected ear infection
Regards,
*** ***

As *** ***'s concern/frustration is understandable, there is no "ball that has been dropped". The physicain who coded this visit, supported it in her documentation and every authority in coding and compliance/ quality and safety (including the Medical Director for the entire system) have been asked to review this visit. A full audit and chart review has been done and the encounter physician (who is no longer at this office) has documented and coded exactly what she believed as being the issue. As much as I wish her carrier would pay for a diagnosis as common as this is in the medical field (not just dental), I cannot change a code simply to get something paid. The doctor believed this to be the problem and coded and documented as such. It is unfortunate when Insurance companies come between physicians and their patients like this

I feel very discarded by this reply and am left with no response That is all is all well in good that your 'records' show all this communications Unfortunately, the 'patient' was not privy to this knowledge I am really tired of going round and round with this and feel that there is nothing left to do but pay it and be done This validates my decision to chance practices for my family's future treatmentRegards,
*** ***

The encounter (and all of the physician provided documentation) has been reviewed by all governing entities at the Corporate Services Center including the Medical Director, the Director of quality and Safety and the manager of coding and compliance and all end up at the same conclusion - that the documentation provided by the physician is consistent with the coding and billing and that nothing is out of place from that standpoint. And although we would never want a patient to have a financial deficit, we cannot alter or change a code the phsyicain has assigend based on their clinical medical decision making during the encounterI would encourage the patient to address why her carrier will not pay for a common chronic condition and get advocacy with her HR / employer who purchased a plan where this can and clearly has happened causing so much duress and frustration
Thank you

Received patient correspondence and have conducted appropriate research.  Upon discussing reseach findings with patient, advised patient to contact payor to request appeal and their reason codes in totality.  Requested patient to follow up with our office upon receiving payor...

response. 
Thank you.
[redacted]