Denied due to missing PA pt is deceased is there a chance to appeal (UHC insurance)
Hello. So I just started working in a specialty clinic a few weeks ago. I handle claim correction, payment postings/followup, and appeals.
And there are two claims that were denied because the clinic was not able to get PA before administering it. Both claims are denied by United Healthcare – medicare advantage plan.
First claim was denied in January. I don't know the reason why they were not able to get PA. The former staff who is tasked to do PAs at that time already resigned. Also, Patient was deceased since May. The drug denied cost around $1.3k
Second claim was denied in June. Different pt. The cost of denied drug is around $75. I asked the current staff who handles both PA and insurance verification why and she admitted it was her mistake for not thoroughly checking enough. She trusted the information written in the referral document from the patient's PCP. The document indicated that the patient's primary insurance is Medicare and secondary is UHC (checked that document myself and yes they did write it like that). The patient also submitted two insurance cards, Medicare and UHC. She did perform insurance verification. She verified Medicare through our EMR while UHC via their portal. However, at that time, she was still a new staff and forgot to double check the payer status of which insurance is primary or secondary. She did not know where to look as well as this was not really emphasized to her during her brief training. So because of this, she was not able to get PA because Medicare (which she thought is the primary insurance) does not require really require PA. Then she just discovered she made a big mistake when the claim keeps getting rejected by Medicare. Turns out the patient only has UHC but with medicare advantage plan. She submitted a reconsideration request via portal but was denied.
So now, I'm trying to appeal both of these claims. Is there any chance that we can still fight for these, especially the first claim since it's a large cost? The provider told me to appeal on the grounds of medical necessity. I'm fairly new about appeals so I read online and they said it's unlikely unless there is a valid reason like emergencies.
Any advise? Thank you.
submitted by /u/Hungry-Bed1644
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