Medical Billing Forum
Payments => Insurance Payments => : thatcuteblonde April 29, 2009, 02:45:19 PM
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Humana is notorious for downcoding E & Ms. There are numerous articles and mentions of this online stating how they have been doing so for years, despite law suits and sanctions against doing so. I recently noticed they have not only downcoded every level four (99214) to a level three (99213) and half the 99213's to 99212's regardless of the diagnosis codes or documentation which they request on every patient. In one case, they even downcoded a new patient office visit (99204) to a 99213!!
I know most people don't bother to appeal this because the minimal reduction resulting in a loss of $20 or so, doesn't seem worth the effort but they've done it so consistantly the $20-$30 per O.V. is really starting to add up. Has anyone figured out how to combat this without writing an individual appeal letter for every patient and date of service? The downcoding is unjustified and, from what I've read, unlawful!
Anyone have any input?
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Here is a portion of a newsletter article that tells you some things you can do:
What can you do?
Third-party payers continue to act in their own best interests, particularly if they're for-profit, publicly held companies concerned about Wall Street performance and quarterly reports. Many turn to aggressive downcoding and payment delay tactics whenever possible.
You're not completely helpless in the face of all this. You can take some action. However, no simple solutions exist to force change or quickly make this payment nightmare go away. Until legislators and regulators step in, providers are pretty much on their own.
For now, these strategies can help you collect the reimbursement you're due in a timely, accurate manner.
Get it in writing. Ask plan administrators to send written descriptions of their requirements for various levels of service. Be certain that such requirements are tied to the provider agreement. If the payer can't or won't provide written documentation, be prepared for unending downcoding disputes.
Find out who's reviewing your claims. If the payer is using an outside agency to review claims and make downcoding decisions, demand written documentation of the standards that the outside agency uses to judge the validity of your claims.
Get a definition of a "clean" claim. It should be included in your provider agreement or, at least, a document incorporated by reference. If it's not defined now, try to have your provider agreement amended as soon as possible.
Bring your staff up to speed. Make sure that your employees who do billing know the requirements for each plan. It may be helpful to create a submission matrix for each plan and have your claims software automatically flag any required field not completed according to a payer's standards.
Use electronic billing. This can be very helpful when your billing system is integrated with a software program that flags questionable information or empty fields. Such an approach should speed up the process and reduce chances for mischief.
Document every claim denied, downcoded or delayed. Report all outrageous behavior to your elected representatives and to your state department of insurance.
Keep accurate records of claims not paid within stipulated time frames. If you're asked to provide additional information, document whether the request is reasonable and if it's made in a reasonable amount of time. Keep records of the additional documentation you provide. (State prompt pay laws require that payers, when disputing a claim, must request additional data within a defined time frame and then resolve the claim quickly.)
Pay attention to your provider agreement. Far too many agreements are signed without payment timing provisions, leaving the door open for payer mischief. Payers can use all sorts of tricks -- including wording such as "Health plan will use its best efforts to pay all claims by the 10th of the month." How can you prove that the payer isn't using its best efforts to pay claims.
Linda Walker
PMRNC
www.billerswebsite.com
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Thanks for sharing that info Linda.
Like you said, most people don't bother to appeal, some don't since it isn't a lot of money (per visit) and some because they don't know how. There are two reasons this is not a good idea. 1. It is a lot of money. If they do it repeatedly and if they get away with it, it adds up. 2. The principle of the matter is that the provider is the one who should determine what was done in the visit (assuming the coding is being done properly). Many times the downcoding is done without office notes.
I read a statistic once that said that 45% of people interviewed do not appeal a denied claim. Think of the savings for the insurance companies.
If you are coding and billing appropriately then you should fight for what is rightfully due!
Michele
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Thanks for sharing that info Linda.
Like you said, most people don't bother to appeal, some don't since it isn't a lot of money (per visit) and some because they don't know how. There are two reasons this is not a good idea. 1. It is a lot of money. If they do it repeatedly and if they get away with it, it adds up. 2. The principle of the matter is that the provider is the one who should determine what was done in the visit (assuming the coding is being done properly). Many times the downcoding is done without office notes.
I read a statistic once that said that 45% of people interviewed do not appeal a denied claim. Think of the savings for the insurance companies.
If you are coding and billing appropriately then you should fight for what is rightfully due!
Michele
Amen to that...........SHOW ME THE MONEY!!
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