Question

You are working with a healthy, 72 year old male who just had shoulder surgery. When billing for his OT services, Medicare denied the payment and stated they believe the treatment was not medically necessary. What step would be most appropriate for the OT to appeal the denial?

a. Write an appeal letter that explains the client's need for the OT services that were provided
b. Ask the payer whether a different intervention would better fit the payment guidelines
c. Correct technical errors in a previously submitted document
d. Listen to Medicare and give up on the billing

Answer 1

The most appropriate step for the OT to appeal the denial from Medicare is to write an appeal letter that explains the client's need for the OT services that were provided.

Step-by-step explanation:

The most appropriate step for the OT to appeal the denial from Medicare is to write an appeal letter that explains the client's need for the OT services that were provided. This appeal letter should provide detailed information about the specific treatment plan, the patient's condition, and the expected outcomes from the OT services. It should also include any supporting documentation, such as medical records or physician notes, to further justify the medical necessity of the treatment.

By presenting a strong and well-documented case in the appeal letter, the OT can demonstrate to Medicare why the treatment was indeed medically necessary for the 72-year-old male patient who just had shoulder surgery. It is important for the OT to clearly articulate how the treatment aligns with Medicare's guidelines and how it addresses the patient's functional limitations and goals.

Correcting technical errors in a previously submitted document may also be necessary if any mistakes or omissions were made. However, the first and most crucial step is to provide a compelling appeal letter that substantiates the medical necessity of the OT services.