Will your records survive the Railroad Medicare Claims Review?

It has begun. 
Railroad Medicare has stated on their website that they are targeting chiropractic claims for audit “due to the high percentage of errors” identified by CERT testing. 
Palmetto GBA, which administers the Railroad Medicare program, states that 10% of all chiropractic claims will be reviewed.  If you receive a request for records for one or more patients please use the following guidelines to submit your information:

  • Provide all documents requested on the Additional Document Request letter.  These include your daily notes (electronic or paper) for the date(s) in question, your most recent exam/re-exam and treatment plan, all outcomes assessment forms the patient filled out, radiology reports and any additional paper documentation pertaining to the date(s) in question.
  • Make a copy for Palmetto and another for your records.  This additional set will help you should your claim be denied.  It will be clear what information was provided to the reviewer.
  • You have 30 days to respond.  If you fail to respond, your claim will be denied on the 45th day.  If your response is received between day 30 and 45 – it may not be processed.
  • You will receive the results of the review in approximately 60 days. 
  • If you disagree with the decision of Palmetto Reviewers you will have 120 days from the decision date to appeal.

Do not delay in responding to this request. 

Medicare will not negotiate an extension.  

Failure to respond will result in a denial - and an increase in your error rate.  

If your claim is denied, we can help you appeal


7 Steps for Responding to Denied Claims (Part 2)

You’ve checked out your coding, your modifiers, your units and your onset dates.  What you submitted meets the generally accepted standards and it was denied!?  It happens every day.  

Most offices don't take the time or have the expertise to appeal those denied services.  Insurance companies "bank" on the fact that less that half of denied or bundled claims are ever appealed.  Don't take those denials - get paid for the services you perform!

#5 - Appeal the decision: Get ready to write! 
Determine the basis for your appeal; incorrectly bundled?  Medical Necessity?  Create an appeal letter that clearly and simply states why this claim should have been paid. Leave your frustration at your office and offer a compelling, fact based, CPT driven reason the claim should be paid.


For an example of an appeal letter for the bundling of 98940 and 97140, click here.

#6 – Review the rules for appeal

Review the EOB or the on-line provider resources for the insurance company’s appeal process, noting the timeframe for receipt of the appeal and the timeframe under which they are required to respond. 

Some carriers require their own appeal form (Blue Cross/Blue Shield, United Healthcare), while others do not.  Keep a copy of the letter/form, documentation you attached, date and address to which the appeal was sent. 

#7 – Appeal the decision.

Mail the appeal – you can send it certified if you prefer, but document what, where and when you appealed the carriers decision.

Be prepared to follow-up if you have not received correspondence or payment regarding your appeal.  Follow-up on these pended claims should begin 4-6 weeks after records are submitted. 

If your office is experiencing a pattern of records requests a thorough review of your billing practices and documentation might be in order.  For assistance in this and other healthcare related matters, contact us at 888.887.5259 or click here.


Getting SSN and DOB


When obtaining information from your patients, please take a moment to obtain their social security number and verify the date of birth.  Cornerstone staff will sometimes have difficulty obtaining claim status without these two pieces of information. 


Patients are sometimes uncertain about releasing their social security number, but it is a required piece of information to process claims.  Please reassure these nervous patients that their information is protected and that we only request data we are required to have!  HIPAA Privacy and Security regulations require that their valuable personal information is protected and used only when required.