Author Topic: Non-par surgery bills--do CCI edits and multiple surgery reductions matter?  (Read 2425 times)


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This is a great website!  I am desperately trying to find a definitive answer to my billing question, and I think this is the place.

I bill for a plastic surgeon who does a lot of ER surgeries.  He is non-par with every company except Medicare.  A typical ER bill includes a surgery, debridement, physician-administered nerve block, and an ER E/M service.

Because it's ER, and neither the patient nor the doctor can choose each other or verify insurance at time of service, claims are usually processed and paid at a good rate.  Recently, however, Horizon has begun to apply CCI edits (bundling) and multiple surgery discounts to reduce the amount they pay significantly.
If that's how they want to process it, I'm okay with it, but then they put $0 as patient responsibility on the EOB, and the patient thinks they have no further obligation to pay when they receive a bill for the balance from us.

Here are my questions: 
1.  Can I balance bill a patient for the difference between the amount charged and the amount paid by insurance in this situation? 
2.  Do I need to worry about CCI and multiple surgery discounts if my doctor is non-par? 
3.  If not, how do I get the patient to understand that when the EOB says that they have no financial responsibility beyond what was paid by insurance?
4.  Can you point me to a law or something concrete that I can show the doctor (and have for myself)? 

Hope this makes sense.  Thanks in advance for your expertise.



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1.  I am not familiar with Horizon, but as long as the patient is not eligible for a Medicaid product and the provider does not par, then you can balance bill the patient.

2.  I would make sure you are using appropriate modifiers when billing to prevent as much bundling as possible.  Obviously the more you can collect from the insurance carrier, the better.  Other than that, I wouldn't worry about the CCI edits.

3.  I would advise the patients that the dr is not in their insurance network.  You cannot control what the insurance carrier puts on the eob.  I would also encourage them to call their insurance carrier.  Many times, they will reprocess to allow the difference in your situation.  When the patient doesn't have a choice, and it's an ER situation.

4.  I don't know where to point you legally to back any of this up.

My stepdaughter got a bill for an ER visit where her insurance only paid a portion, dr was non par.  I called her insurance myself (which happened to be Horizon) and they told me that they process as in network first, and if the provider won't accept it as payment in full, then they reprocess and allow billed charges, but they must go thru that process and patient must call in to request reprocessing.

If anyone else has any info on this, please respond.

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Thanks, Michele.  I actually have a standard message that I put on the first statement (which is generated when we receive partial payment) that goes to an ER patient, which states that the patient should call their insurance carrier and ask for the claim to be reprocessed to pay in full because it's an ER visit.  This has been working well, until Horizon started saying no due to CCI edits and multiple surgery payment rules--rules which have not applied in the past.

I can't even call and speak to anyone at Horizon because my doc is non-par.  Non-par providers get routed directly to the IVR and disconnected when we choose the choice to speak to an agent.  So the responsibility is on the patient.

I guess I will have to meet with my doc and start having him use -59 mods on all but the primary procedure.  I am a CPC, and that goes against coding guidelines, but the insurance companies are not playing fair here.

I'd appreciate hearing from anyone else who has experience in this area.