Author Topic: LHCC Ins - Getting E/M Paid is Difficult :-( - Pls Helpppp  (Read 2362 times)

shakthi345

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LHCC Ins - Getting E/M Paid is Difficult :-( - Pls Helpppp
« on: March 30, 2016, 02:35:09 PM »
Hello All ,

Currently wrking with Dermatology spl in Alabama , Mississippi & Louisiana states Where LHCC ( Louisiana Healthcare Connection) plays a major role. Now a days Getting Paid with this carrier is really a tough task . Let me explain . When claim submitted with E/M and surgical codes ( with mod 25) , surgical codes getting paid , E/M alone denied as with Remark code - M16 .. When Called for this denial , spoke with Rep claim denied CPT 99213 for processed inclusive with overall services. Stated to rep the CPT 99213 was billed with 25 modifier. Rep however stated claim was processed as per State Medicaid Reimbursement Guidelines and requested send reconsideration form to P.O. Box 4040.Farmington,MO 63640. Time limit is 90 days from EOB.

Based upon the above , we need to submit an Reconsideration form to process the E/M code . At last , when completing all this bla bla process , the claim hits the TFL range.

Can anyne help me on this to get Paid with this E/M codes initially without this forms...etc.. Awaiting for the reply Frnds... :D

kristin

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Re: LHCC Ins - Getting E/M Paid is Difficult :-( - Pls Helpppp
« Reply #1 on: March 30, 2016, 04:11:27 PM »
Is the EM code being submitted with separate dx's then what is being diagnosed on surgical CPT code? If not, and unless the tx note you submit really shows that the EM was above and beyond the portion of the EM code already factored into the surgical code, you will be out of luck.

If you are using separate dx's(because it is warranted, not just to get paid), and the EM is truly separately identifiable by the tx note, you will have to continue to appeal the denials, if the insurance company has put an edit into place automatically denying EM's submitted with surgical codes, while trying to appeal to them about the edit. Twice, with different insurance companies, I have run into this issue. The first one(Aetna), after complaining constantly to them, and sending evidence as to why their edit was wrong, changed their edit(they had numerous providers complaining, not just us). The second one(Humana), they absolutely refused to listen to reason, so we dropped that plan. It was costing us more time to do the appeals then they would pay us for the EM code, when we would finally win the appeal.

Medicaid plans are awful to deal with, so I wish you luck!

shakthi345

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Re: LHCC Ins - Getting E/M Paid is Difficult :-( - Pls Helpppp
« Reply #2 on: April 01, 2016, 02:21:32 PM »
Thanx 4 ur reply buddy...!

Awaiting for some more Experts thoughts on this....! Pls REply  :)

Michele

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Re: LHCC Ins - Getting E/M Paid is Difficult :-( - Pls Helpppp
« Reply #3 on: April 06, 2016, 11:32:23 AM »
Is the EM code being submitted with separate dx's then what is being diagnosed on surgical CPT code? If not, and unless the tx note you submit really shows that the EM was above and beyond the portion of the EM code already factored into the surgical code, you will be out of luck.

If you are using separate dx's(because it is warranted, not just to get paid), and the EM is truly separately identifiable by the tx note, you will have to continue to appeal the denials, if the insurance company has put an edit into place automatically denying EM's submitted with surgical codes, while trying to appeal to them about the edit. Twice, with different insurance companies, I have run into this issue. The first one(Aetna), after complaining constantly to them, and sending evidence as to why their edit was wrong, changed their edit(they had numerous providers complaining, not just us). The second one(Humana), they absolutely refused to listen to reason, so we dropped that plan. It was costing us more time to do the appeals then they would pay us for the EM code, when we would finally win the appeal.

Medicaid plans are awful to deal with, so I wish you luck!

This is exactly what I would have put.  Well explained Kristin!
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Re: LHCC Ins - Getting E/M Paid is Difficult :-( - Pls Helpppp
« Reply #3 on: April 06, 2016, 11:32:23 AM »