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Part 2: Strategic Compliance with the Law
You work for a small managed care organization (MCO) "Splendid Healthcare" that owns a hospital and two provider clinics in. Your MCO has 100 employees and provides health insurance through a contract with a large insurance company "Insurance Inc." Insurance Inc. follows the ACA preventive service requirements and covers influenza vaccines for your employees. Lately, these claims have been rejected by Insurance Inc. You call the Insurer and they request medical records to support the payment request for the 30 employees whose immunization claims were denied. The Insurer says you are billing the incorrect code.
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