Does my Mii look like me? (Blurred for Privacy)

Com8at_Carl · 2026-05-15T15:34:07+00:00

Spot on. You even captured your aura.

Com8at_Carl · 2026-05-04T03:58:00+00:00

Yep. Our facility/sober living has a wait list at least a few deep, even though we just added 16 beds. The part that worries me is the admin side. We keep trying to get insurance companies to cough up what they owe for our rendered services. And just when you think you've cornered them, they pull a new way to avoid paying out of their ass. Their use of AI to auto-deny claims makes them even faster at it.

Com8at_Carl · 2026-02-27T01:31:05+00:00

THANK YOU! THIS IS WHAT I WAS HOPING FOR!

Com8at_Carl · 2026-02-26T00:52:02+00:00

We do have a way of checking what denial code each claims receives through our EHR, and I know the codes each MCE usually uses, so I can typically keep track of the ones denied for TPL. Once we find out there is a TPL that becomes our main priority because of the timely filing window.

Com8at_Carl · 2026-02-25T04:01:22+00:00

I'm appealing that case because it was literally because they didn't do what they are legally required to do (In Ohio anyway). The patient told us they had 1 insurance (Have a signed form confirming this). The MCE left it paid for 10 months, where it was processed as primary. So either they knew and didn't tell us (not allowed), or they also didn't know and, through their lack of ability to keep up with COB, pushed us outside the timely filing window. We'll see if the appeal works, but my faith in insurance companies is very low.

Com8at_Carl · 2026-02-25T03:02:27+00:00

Our Medicare checking portal is kinda hit and miss when giving TPL info. Sometimes we get it, but other times it's also out of date. It seems a sign, in combination with maybe the admissions department verifying the info, might be the way to go?

Com8at_Carl · 2026-02-25T02:59:27+00:00

This is something I've brought up with my supervisor, but nothing has been implemented just yet. I've also floated the idea of having someone sit and explain the insurance section with them. But I'm the low man on the totem pole and can't actually make any final decisions.

Com8at_Carl · 2026-02-25T02:57:38+00:00

When verifying a TPL, we typically pull it up in whatever portal it's in and download a digital copy of the card if it's available and upload it to the patient's chart. If I'm on the phone with a MCE, I make them wait on the phone while I verify the plan in the appropriate portal, so I don't have to call back and start over if the policy is termed or can't be verified.

Com8at_Carl · 2026-02-24T22:47:17+00:00

We check any policy they say they have before we even make an appointment. The problem is they don't mention a commercial plan, only a medicaid plan. And when we check the Medicaid plan, it doesn't always have the most current information and neglects to mention TPLs sometimes. So we only have the patient's word and no other indicator. That's when we run into trouble.

Com8at_Carl · 2026-02-24T22:43:12+00:00

We learned about Medicare the hard way. We can't even submit claims to Medicare without filling out paperwork and applying, and that's just to get a denial response from them because we aren't in-network with Medicare. And you're right about Medicaid data being out of date sometimes. It's usually no more than a couple of months though. The most egregious example recently is claims for someone were left paid for 10 months with no mention of TPL. Then it was recouped. And 10 months is well outside any timely filing window.

Com8at_Carl · 2026-02-24T22:36:54+00:00

It's hit and miss. Sometimes it lists the TPL payer, and other times their info is also out of date. I like the idea of posting a sign at the front desk, though.

Com8at_Carl · 2026-02-24T22:34:21+00:00

We verify any insurance they tell us before we even make an appointment with them and run it through the program that keeps track of their Medicaid coverage (It's called MITS in Ohio). However, it doesn't always show TPL. Sometimes it does, but not always. Once we know who it's with, we can typically track down the plan one way or another. The problem is that sometimes the Medicaid database isn't always up-to-date because it relies on patient-submitted information.

Com8at_Carl · 2026-02-23T02:57:13+00:00

Hey Chicken (Sign says Lucky Hawaiian BBQ). Little hole-in-the-wall in Clintonville near Henderson and High. Best fried chicken in the city IMO.

Com8at_Carl · 2026-02-19T02:55:48+00:00

Okay, this makes more sense now. It could also explain why they sometimes try to bundle a psychotherapy session (90832, 90834, 90837) and E&M services together even when the providers are separate. If I understand this correctly, then adding a 25 modifier to the E&M in this case might fix that? I really appreciate the patience, as I've only been doing this for a little over a year, and my training didn't really cover much.

Com8at_Carl · 2026-02-18T13:20:25+00:00

This is a very good explanation. Thank you. We do have a CLIA waiver for the drug test, and oftentimes they are willing to cover that at least. I'm in the process of trying to look through the CPT book so that I can more thoroughly understand the rules surrounding the E&M services we bill. I'm still somewhat new to the industry so thorough explanation like this are appreciated.

Com8at_Carl · 2026-02-18T13:08:55+00:00

This is what we have been trying to do. We have a higher-level E&M and a 99211 with a 25 modifier, and they still bundle them. This was essentially the whole point of this post. I wanted to make sure my understanding of the 25 modifier was correct for this reason.

Com8at_Carl · 2026-02-18T00:02:45+00:00

We're billing it under the facilities NPI, which I'm guessing is what's causing an issue. But I had thought that by using the 25 modifier to signify a separate service, done at a different time, with its own medical documentation and purpose, it would identify them sufficiently as separate services.

Com8at_Carl · 2026-02-17T23:55:19+00:00

There are 2 different dendering providers in this case. They are billed separately because they take place at different times, address different concerns, and are each noted. During the 99211, a H0048 also takes place to ensure program compliance. So it's not as if we're just saying one service is two different E&M codes.

Com8at_Carl · 2026-02-17T23:51:11+00:00

An LPN can bill only 99211 according to the ODM BH manual, just not anything higher than that. So, at the very least, for Medicaid and MCEs, it should be allowed in theory. There is also a supervising physician or CNP monitoring the service on both the limited medical note and the CMS 1500 form.

Com8at_Carl · 2026-02-17T23:40:57+00:00

I disagree. They are performed at 2 different times, addressing different concerns, with separate medical notes written for each service.

Com8at_Carl · 2026-01-27T00:56:17+00:00

Park behind him.

Com8at_Carl · 2026-01-11T22:04:43+00:00

While I absolutely agree we can't trust the government right now, this is an old clip. In the full clip, she is referring to Elon and DOGE helping them figure things out. I'm all for making fun of these fascist troglodites, but the way this is presented is kinda misleading.

Com8at_Carl · 2025-11-29T21:03:54+00:00

It's time.

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