Author Topic: Insurance company reducing/denying payment.  (Read 4355 times)

dekenn

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Insurance company reducing/denying payment.
« on: January 14, 2015, 01:02:45 PM »
Hello All,
I have two issues that I've been trying to get resolved and I'd like to know if anyone out there is having the same issue, and if so, how did you go about appealing them, and were you successful?

Issue 1: One of the insurance companies we deal with (Magnacare) is reducing the payment of x-rays by 50% when x-rays are taken bilaterally. They pay 100% for the first foot, then reduce the payment for the second foot, stating that it's a "secondary procedure/reduction in allowance". I've tried calling, and they state "that's our policy", however, nothing is every forthcoming in writing. Is there some way I can appeal this?

Issue 2: I have two different insurance companies that won't allow any payment for cast materials when billing for the application of a cast. I have appealed both to both of these companies with printouts from various websites showing that cast materials are billable separately. Again, neither company can give me this in writing specifically, just "it's not a covered benefit". Now, I understand that some of the policies don't cover any DME and will not cover this, but then shouldn't it be patient responsibility? Why is it that the doctor doesn't get paid at all for this? They refused to reprocess the claims showing that it's patient responsibility. Again, any suggestions on how to approach this?

Thank you all so much for any advice/input!

PMRNC

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Re: Insurance company reducing/denying payment.
« Reply #1 on: January 14, 2015, 06:31:57 PM »
Before getting specific..

Do you have a contract with the carriers? If so have you looked at those first?

2nd.. if these are ERISA based claims do you have copy of the plan benefit summary?

Linda Walker
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Merry

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Re: Insurance company reducing/denying payment.
« Reply #2 on: January 15, 2015, 11:54:10 AM »
I have never seen bilateral x-rays paid any other way. They even will do that with an MRI of 2 different body parts on the same day when done in a medical office. When performed in a hospital based radiology practice reimbursement is different.
 

dekenn

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Re: Insurance company reducing/denying payment.
« Reply #3 on: January 15, 2015, 02:12:25 PM »
Yes, we are participating with all three insurances. None of them are government health insurance plans, they are all private employer plans, (Magnacare, Barnabas Health and Qualcare) Not sure what would make them ERISA plans? None of the "contracts" go into specifics about how different codes are paid. They pretty much state "according to our fee schedule". You can get the reimbursement rates by requesting certain codes, but they will not release the whole fee schedule. As far as the plan benefit summary, they won't release that either. The employee has to request it and if they want to, can let us see it.
As far as the cast supplies go, I have other insurance companies that don't pay it, or will only pay half, but they always show it as a non-covered benefit and patient responsibility.
As far as bilateral x-rays, this is the ONLY insurance company that does this! Medicare and Medicaid don't even cut the 2nd one by 50%.

Merry

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Re: Insurance company reducing/denying payment.
« Reply #4 on: January 15, 2015, 03:47:05 PM »
Interesting..I have my Medicare paperwork in front of me and they are not reimbursing 100% on a bilateral xray.

dekenn

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Re: Insurance company reducing/denying payment.
« Reply #5 on: January 15, 2015, 03:51:44 PM »
Really? How do you bill it? I was taught to bill separate lines with RT and LT modifiers. If he takes 3 views of the right and 3 views of the left foot, I would bill
73630 RT
73630 LT

Merry

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Re: Insurance company reducing/denying payment.
« Reply #6 on: January 15, 2015, 03:53:51 PM »
I just did a search and it looks like it depends on the carrier. And some require a -50 modifier. Some require two lines with a RT and a LT for each line item.

kristin

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Re: Insurance company reducing/denying payment.
« Reply #7 on: January 15, 2015, 09:15:50 PM »
For the MAC's I bill for(NGS, FSCO, Novitas, Cahaba), and all the commercial insurances I bill for in Illinois, Georgia, Florida, and Pennsylvania, they want bilateral x-rays billed on two lines, with the RT/LT modifier. None of them apply a discount on the second set of x-rays.

It sounds like Magnacare is considering an x-ray to be a procedure, when it is not, it is a diagnostic exam, if you will, and in a totally separate category for reimbursement.

dekenn

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Re: Insurance company reducing/denying payment.
« Reply #8 on: January 20, 2015, 09:55:55 AM »
Ok, I think I have some ideas about appealing the x-ray reduction.
Any input on how to appeal the casting material being a write-off? Ideally, I'd like to convince the insurance companies to pay it, but will settle for them making it a non-covered service that is patient responsibility.
Anyone have any experience with cast materials?
Thanks

Rclausing

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Re: Insurance company reducing/denying payment.
« Reply #9 on: May 09, 2015, 05:01:10 PM »
"Issue 1: One of the insurance companies we deal with (Magnacare) is reducing the payment of x-rays by 50% when x-rays are taken bilaterally. They pay 100% for the first foot, then reduce the payment for the second foot, stating that it's a "secondary procedure/reduction in allowance". I've tried calling, and they state "that's our policy", however, nothing is every forthcoming in writing. Is there some way I can appeal this?"

As stated, these are diagnostic tests, not procedures so shouldn't be subjected to the multiple procedure rule. And I would appeal on those grounds. While you're at it, see if you can get a hold of a provider representative that is responsible for contracting, credentialing etc. You'll need to check your contract and verify there isn't something in their reimbursement policy that describe your situation. It may be you have a contractual obligation to accept these terms (seems unlikely). One thing you want to look for is any reference to the Correct Coding Initiative. If it is stated in your contract that they follow the CCI edits, then they are contractually obligated to allow 100% for the second diagnostic. A provider rep (if they have them), can assist you in getting your denied claims paid, and help prevent future denials - if applicable.

Ultimately, if you choose to play hardball as a last resort, you can try to convince them that processing claims outside of the CCI rules constitutes fraud under 18 U.S. Code § 1035 - False statements relating to health care matters:

(a) Whoever, in any matter involving a health care benefit program, knowingly and willfully—
(1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; or
(2) makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any materially false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry,
in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 5 years, or both.
(b) As used in this section, the term “health care benefit program” has the meaning given such term in section 24 (b) of this title.

I've used this before in appeals where an insurance co. was inappropriately bundling surgical procedures, and the physician was ready to take them to court over the situation. In that instance, we got a large check from them reprocessing claims. And it arrived within 7 days.  ;D   Ah, the joys of Claim Check.   >:(

Ancillary medical materials are almost always bundled into the associated procedure. I'm surprised anyone pays for the casting plaster. If you are using some special material that could be considered outside the scope of a normal cast, some sort of ABN might be in order so that the patients are aware that it will be their responsibility and/or have a choice of using something else.

PMRNC

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Re: Insurance company reducing/denying payment.
« Reply #10 on: May 09, 2015, 05:32:47 PM »
Looks like someone used to work for insurance claims.. you had me at "claim check" and in another post on all nations clauses :)
Linda Walker
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Rclausing

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Re: Insurance company reducing/denying payment.
« Reply #11 on: May 09, 2015, 05:41:55 PM »
Looks like someone used to work for insurance claims.. you had me at "claim check" and in another post on all nations clauses :)

I did a 6 mo stint with a BC/BS TPA in an investigative unit for individual policies working as a temp... but that is all.  Know thy enemy, I say. I have over 20 years experience as a medical accounts receivable specialist. Worked for pretty much every specialty type at one time or another, even the dreaded DME. I meet VERY few people that have dedicated as much time as I have researching the best ways to turn physician services into cash - and from the looks of your posts, you could be one of them! I wish you were in Oregon, I've been out of the game for a bit and had an old client call me up the other day wanting me back. It turns out I need the job so I'm back to the grind. Would love to have someone to talk to locally so I can catch up on what's been going on.

PMRNC

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Re: Insurance company reducing/denying payment.
« Reply #12 on: May 09, 2015, 05:48:18 PM »
Quote
did a 6 mo stint with a BC/BS TPA in an investigative unit for individual policies working as a temp... but that is all.  Know thy enemy, I say. I have over 20 years experience as a medical accounts receivable specialist. Worked for pretty much every specialty type at one time or another, even the dreaded DME. I meet VERY few people that have dedicated as much time as I have researching the best ways to turn physician services into cash - and from the looks of your posts, you could be one of them! I wish you were in Oregon, I've been out of the game for a bit and had an old client call me up the other day wanting me back. It turns out I need the job so I'm back to the grind. Would love to have someone to talk to locally so I can catch up on what's been going on.

I spent my first 14 years in the business on the enemy line <g>  You can email me linda@billerswebsite.com
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Rclausing

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Re: Insurance company reducing/denying payment.
« Reply #13 on: May 09, 2015, 05:56:53 PM »
Thanks, I just sent a friend request to the FB billerswebsite page. I'll send another to your personal FB, hope you don't mind. I hate to admit how much I use FB...  ::)

dekenn

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Re: Insurance company reducing/denying payment.
« Reply #14 on: May 11, 2015, 09:27:45 AM »
Rclausing, Thanks so much for your response! I still had not gotten anywhere on the x-ray issue, but I will follow up with your suggestions. Thanks for taking the time to help out!

As for the cast material, it's not the casting plaster, it's the Q codes for the fiberglass material for the post-op casts, or fracture casts.  Any thoughts would be most appreciated!