Medicare Claims

This was a routine office visit with Dr. Sarah Johnson for a general adult medical examination. While the claim was processed and approved, our AI analysis identified a potential billing inconsistency. The visit was billed as a diagnostic office visit (99213) in addition to an annual wellness visit (G0438). Typically, if the primary purpose is preventive, the diagnostic code should not be applied unless a separate, significant medical issue was addressed. This has resulted in a $19.20 coinsurance charge that may be contestable.

Comprehensive outpatient diagnostic workup including metabolic panel and thyroid function tests. All services were fully covered by Medicare with no patient responsibility.

Prescription filled for Lisinopril 10mg (30 day supply). Covered by Part D plan with standard copay/coinsurance.

Inpatient cardiac valve replacement surgery. 100% covered by Part A benefit after deductible (which was previously met).

Recent imaging service flagged for review. The provider billing name does not match the NPI records on file, which may delay processing or lead to denial.

Physical therapy session denied due to missing medical necessity documentation. The provider failed to submit the required plan of care. Appeal recommended.

Lab test denied as a duplicate of a service already paid for on the same date. Our analysis shows this Lipid Panel matches another claim processed on the same day. You are not responsible for payment of duplicate billings.

Specialist visit with non-participating provider resulting in excess charges. The provider charged 15% above the Medicare approved amount, which is your responsibility. While the claim was approved, you paid $30.00 more than you would have with a participating provider.

Home health skilled nursing visit. 100% covered by Part A benefit. Medicare generally covers home health care in full when the patient is homebound and requires skilled care.

This claim is for the first month rental of a Continuous Positive Airway Pressure (CPAP) device. The provider charged $1,200.00, but the Medicare approved amount is $800.00. Medicare paid 80% ($640.00) and you are responsible for the 20% coinsurance ($160.00). This is a standard coverage rate for DME.