Need advice about a very costly corrected claim issue...

[TMCGEATH]

I am ashamed to admit that I billed the wrong code for a mental health counselor. She has hour sessions which is a different code compared to 45-50 minute sessions. I billed the 45-50 minute code. I did not realize I had done it until she handed me the EOB's and commented how it seemed several payments were $8-$10 less than usual. I looked into it and was horrified to realize what I had done. I immediately told her about my mistake and that I would do my best to get her the rest of the reimbursement for those dates of services.

I called the insurance company and spoke to a claims rep so they could tell me exactly how to submit a corrected claim.

She told me to put all the dates of service on a paper claim and write "corrected claim" on the top and underneath that, what was being changed so I wrote "CPT code correction".

Weeks later, my provider gave me some EOB's and  I saw that they had paid the full amount again for the corrected code for one of the dates of service.

I guess I should have called right then but I didn't because silly me, I assumed that their system would catch it and just take that amount back from a future claim like I have seen done before in other situations.

When my provider gave me more EOB's a few weeks later, I saw that they had done it for 2 more dates of service. This is when I decided to call.

To my horror, I was told that yes, she could see the copies of my paper claims with the wording written on the top but that it was not enough information to determine exactly what had to be done so they were just paid again and now the provider would have to pay them back!

We are talking about $735 because I made this wonderful mistake on 4 clients with multiple dates of service...

I asked why the provider wasn't called or notified if paper claims were received with hand written information on the top that was unclear. I was told that there is not enough manpower for that, it just isn't done...

I asked why they couldn't just take the amount due back from future claim payments but was told that wasn't done either...

So, from here I don't know what to do and how to approach my provider to prepare her that she will be getting a letter or invoices or something telling her she owes $735. She won't be completely shocked when I tell her because I was keeping her updated on the whole situation. She was aware that this insurance company was paying double for those claims.

I charge this provider a flat rate per paid claim and when this happened, I reduced the per claim rate and didn't get paid as much because it was my mistake.

Yes, I originally submitted the wrong codes but did exactly what the insurance company told me to do to correct them which wasn't the right thing to do.

I am not sure what I could have done differently either - she takes the checks off the EOB's and then eventually gets the EOB's to me so she would have already cashed the checks long before I could have maybe attempted to stop payment on the check or something. But then again, the check would probably have more than just the  dates of service that I goofed on - stopping payment on the check would mean her not getting any payment  for awhile until the mess was figured out. Even calling when I noticed the first double payment wouldn't have helped because all the corrected claims were submitted the same day and they were all paid out in the same week.

From a business standpoint, I'm not sure what the correct thing is to do...The most extreme would be to do her billing for free until the amount I would have charged her equals the amount she has to pay back - but for mental health and her client load, that would be like 4 months of free billing!

Advice please!!!!

[PMRNC]

First thing I would ask is .. "Why are you coding?"   Does your contract state the providers responsibility to give you proper coding or are you responsible for coding?  That is something you want to think of to prevent this from happening again.

What I would have done from the get go was return the checks with a letter explaining problem, along with corrected claims. Returning the EOB's/Check allows the company to "reverse" the claim (back it out) and process correctly.   However that's hindsight, some might disagree with me on this but I would still return the money, send a letter and corrected claims explaining the error. If you don't return the monies they will either take from future claims or request refund anyway so if you do this all at one shot it's nice and clean. They will backout and reverse the claims, process correctly and send check for correct amount due.

That's how I would do it but some might disagree with me .. I like clean books. LOL

[rdmoore2003]

I agree with Linda. 
Do you do the coding?   Also, I am a bit confused, how many claims did this happen with?  If only a few claims that were missing $8-$10, how did this turn into $735?  I also do mental health billing, and if this counselor already knows the issue of what happened and you have received double payments, she should not have an issue of refunding.

[TMCGEATH]

Unfortunately, the provider does give me the CPT code but I just lost my mind and billed the wrong one - Right now I only bill for mental health providers and all of them EXCEPT this one uses 90834 (45 minutes) but she uses 90837 (60 minutes) with the insurance companies that will allow her to do that without authorization so it's not even all her clients, just some of them - I was just doing a lot of billing one day and forgot to bill that other code for her for those insurance companies that allow it. I really messed up!

By the time she gives me the EOB's she has already deposited the checks sometimes weeks before so I couldn't return the checks in this situation...

The reason the amount is so high is that I do her billing once a month. So these 4 patients had seen her once a week for 3 or 4 weeks so I billed somewhere around 13 sessions with the wrong code which the insurance paid the full amount for again the 2nd time while I was trying to correct the claim- like $68 so $68 X 13 sessions = way too much money!!!

Another lesson to myself or maybe I should say continued proof that I need to teak some things as I grow!!

[rdmoore2003]

If it is Blue Cross/Blue Shield, they will recoup the money off of next payments.  Any other carriers, I would just call them and find out what their requirements are and the address to send refund.   
Also, if I am understanding this correctly, she is just giving you the superbills to go off of and not the actual notes.   I personally, will not just code what is given to me, I must see the actual documentation to make sure what I am coding is covered through the documentation. If I coded what was given to me, 20% of the monthly billing would be WRONG!  I have a bit of OCD!

[PMRNC]

By the time she gives me the EOB's she has already deposited the checks sometimes weeks before so I couldn't return the checks in this situation...

The reason the amount is so high is that I do her billing once a month. So these 4 patients had seen her once a week for 3 or 4 weeks so I billed somewhere around 13 sessions with the wrong code which the insurance paid the full amount for again the 2nd time while I was trying to correct the claim- like $68 so $68 X 13 sessions = way too much money!!!

I still say best way is to refund the full amount and let them back out and reprocess all claims. JUST make sure you send a letter and corrected claims!

If it is Blue Cross/Blue Shield, they will recoup the money off of next payments.  Any other carriers, I would just call them and find out what their requirements are and the address to send refund. 

The problem with that is it is a messy task.. the incorrect claims are from one patient's file. It does throw off the books when you have them taking the payments off of other patients/claims. It's just so much neater to send back the money and let them re-process.   When a carrier takes payment off of other claims it messes up the audit trail.

[rdmoore2003]

[The problem with that is it is a messy task.. the incorrect claims are from one patient's file. It does throw off the books when you have them taking the payments off of other patients/claims. It's just so much neater to send back the money and let them re-process.   When a carrier takes payment off of other claims it messes up the audit trail.

Every time I have attempted to send BCBS refunds, they have always returned the refunds and sent letter stating it will come out of next eob.  I have spoken with our provider relations rep and sent in letter with corrected eobs, etc and bcbs of la will not take the refund check.

[PMRNC]

Every time I have attempted to send BCBS refunds, they have always returned the refunds and sent letter stating it will come out of next eob.  I have spoken with our provider relations rep and sent in letter with corrected eobs, etc and bcbs of la will not take the refund check.

participating?? I've only dealt with Par in this instance but I demand supervisor on the line. I don't send the check unless I have a name and documentation to indicate who I spoke with.  As a former claims examiner myself we LOVED this because it was easier to back out claims/reprocess than it was to deduct from other claims (a lot more goes into than people think). We always took the refund as the preferred method to take care of an error like this. I have dealt with various state BCBS (Par only though) and never had a problem. I get the name of the person I spoke with and I get name to whom I was told to send the corrected claims and check to. When claims are received, if there is a check attached, that check is assigned the same batch claim number as the claim and is NOT given to the claims department. ONCE it's given batch number as accepted, the insurance carrier is libel to process it!   IT Is NOT good practice to have overpayments adjusted to other patient's claims.

[rdmoore2003]

I am par.