Problems Affecting Budgetary:Performance Reimbursement Problems The manager may be called upon to help with problems of reimbursement. Here are some examples:
● Insurance company disputes charges for a patient stay and refuses to pay them. The insurance company thinks patient should have been discharged a day sooner and refuses to pay for last day of stay because a good clinical reason to be in the hospital isn’t documented.
Here are three alternative solutions:
1. Ask the physician to elaborate on the clinical reasons why the patient necessitated another day stay in the hospital and submit that documentation to the insurance company.
2. Negotiate the charge with the insurance company and take a settlement on payment that is agreeable to both parties.
3. Have an internal utilization review group go through the patient’s chart and extract lab values, clinical presentation symptoms, testing, etc., that were done on day of stay being disputed and submit to insurance company as an appeal to denial to pay, demonstrating necessity to stay.
● Patient disputes charges during stay and refuses to pay them. The patient gets a PICC line (invasive procedure, longer term intravenous line) placed for IV antibiotics to be infused for one to two weeks. The PICC line is placed because one to two weeks of antibiotics is not something typically a peripheral IV line would be used for because they don’t hold up as well and can’t infiltrate or the patient could get phlebitis. Then, after the PICC line is placed, two days later the doctor decides to discontinue IV antibiotics and remove the PICC line. The patient refuses to pay for the PICC line because it wasn’t used for one to two weeks as the doctor had originally said and feels he should not pay for the doctor’s “change of mind.”