Author Topic: Improper multiple procedure reductions.  (Read 2845 times)

Questhrr.com

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Improper multiple procedure reductions.
« on: October 23, 2015, 09:43:40 AM »
Could I please get advice on my problem.  Also, please understand that I'm not a biller and don't know anything about billing and coding.  What I do is recover improperly denied, repriced, and underpaid provider reimbursements.

I have a (out-patient surgery center) client who is not in-network with any insurers or PPOs.  So, UHC is repricing their claims using multiple procedure reductions ("MPR").  Then, after they reprice the claims, they inform the patients through EOB's and letters that the patients are not responsible for the difference between the provider's billed charges and UHC's repriced amounts.  Is this legal?  Can they actually tell a patient that they're not responsible for the difference when there's no contract with the provider?

Also, their MPR amounts are ridiculous.  It's based on a 100% U&C for highest procedure charge, 25% U&C for second highest procedure charge, and 10% U&C for each additional procedure.  I thought that it's typically 100% for first procedure and 50% for any other procedures.  And, I wasn't aware of a 10% reduction for other procedures.  Below is what their repricing sheet reveals.

RCC                HCPCS                APC                Description                                                           Billed           Repriced Amount

761                    28124L           0055              Level I Ft Musculoskeletal                                       $7,919.70                 $5,463.76
761                    28086L           0055              Level I Ft Musculoskeletal                                       $4,443.95                      $546.38
761                    28270R           0055              Level I Ft Musculoskeletal                                       $7,919.70                 $1,365.94
761                    28286R           0055              Level I Ft Musculoskeletal                                       $7,919.70                      $546.38
761                    29515L           0058              Level I Strapping and Cast                                      $472.70                         $335.22
761                    29515R           0058              Level I Strapping and Cast                                      $472.70                         $335.22
761                    64450L           0206              Level II Nerve Injections                                          $1,458.70                      $104.99
791                    64450R           0206              Level II Nerve Injections                                          $1,458.70                      $104.99
                           Total                                                                                                          $32,065.85                  $8,802.88

Out of this bill for $32,065.85, they repriced the claim to $8,802.88 and then paid that amount, but then wrote off the remaining balance and informed the patient that they are not responsible for the remaining $23,262.97.  I spoke with UHC's Senior Counsel and she informed me that MPR is the norm and they do not expect their member's to pay the difference because of the fact that this is the norm.  I do understand MPR, but I don't think these percentages are the norm, and I don't know if they can legally tell the patients they are not responsible for the difference.

Has anyone else had this issue and how did you handle it?  Could I please get some opinions on if this is legal and how I should appeal this? 

Thanks,

Kevin
« Last Edit: October 23, 2015, 09:47:14 AM by Questhrr.com »

Michele

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Re: Improper multiple procedure reductions.
« Reply #1 on: October 23, 2015, 10:28:33 AM »
I spoke with UHC's Senior Counsel and she informed me that MPR is the norm and they do not expect their member's to pay the difference because of the fact that this is the norm.



First of all I want to say I am not qualified to give you legal advice.  My advice is based on my 25+ years of billing and working for a large insurance carrier. 

(Wow!  I'm old enough to say I have 25+ years experience??  That alone is freaking me out.  :) )

Anyway, what bothers me most about what you said is the line above.  Their senior counsel said they "do not expect their member's to pay the difference"??  This isn't about what they expect or not, it's about what they legally can or can't tell the patient.  I believe since your client is out of network and they have no signed contract with UHC they can bill the patient anything they want.  The patient must be notified up front that the client does not participate and hopefully have signed a statement stating they understand that fact and that they will be responsible for the entire bill.

If it were me I would contact Senior Counsel back and specifically ask "Is it legal for you to tell the patient that they do not have to pay the difference if they do not have a signed contract with the provider?"  If they say yes, ask them what that is based on.  I would not accept an answer saying what they think or expect, but only what is legal.

I wish I had more legal background.  This seems wrong.

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Questhrr.com

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Re: Improper multiple procedure reductions.
« Reply #2 on: October 23, 2015, 10:47:56 AM »
Thank you Michele.  I guess that for legal purposes, I should state that I am only seeking personal opinions, knowledge and advice.  I am not seeking legal advice or legal opinions.

Any personal advice or knowledge from anyone would help.

Kevin

kristin

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Re: Improper multiple procedure reductions.
« Reply #3 on: October 23, 2015, 02:50:35 PM »
I have a question...is that billing what the surgeon billed, or what the ASC billed for their portion?

Questhrr.com

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Re: Improper multiple procedure reductions.
« Reply #4 on: October 23, 2015, 02:54:55 PM »
I'm not sure.  I just know that the billing is from the biller for the ASC.

RichardP

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Re: Improper multiple procedure reductions.
« Reply #5 on: October 23, 2015, 05:18:21 PM »
Re. services performed at an ASC:

1.  The provider who provides the service charges his patient for the service performed.

2.  The ASC charges that patient a facility fee.

There is no correlation between 1 and 2.  You cannot get a useful response to your questions without knowing whether whether the ASC is a participating facility with UHC and whether the charges you mention are from the ASC or the provider.

The provider is not a client of UHC, but maybe the ASC is?

We have clients who do not participate in any insurance (although we bill the patients' insurance as a courtesy to the patients).  The providers have a blurb on their patient intake form that notifies the patients that the doctor does not participate in the patient's insurance and that the patient is responsible for the entire charge for the visit.  The patient is required to sign, acknowledging that they understand they alone are responsible for the fee for the provider's services.

Since the providers have no contract with any insurance carrier, no insurance carrier has any legal authority over what the provider charges.  The carrier may have legal authority to require a patient to see an in-network doctor and may refuse to pay the patient for services recieved by an out-of-network doctor.  But that is the extent of their authority.  Check with a health-care attorney for your state for verification.

Medicaid and Medicare are government programs rather than commercial, and have different rules than those described above. 

Questhrr.com

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Re: Improper multiple procedure reductions.
« Reply #6 on: October 23, 2015, 05:30:53 PM »
Hello Richard.

Well I do know that the bill is from the ASC and neither the provider or ASC are contracted with UHC.  I'm positive that UHC cannot just reprice medical claims and write off the difference when they don't have contractual right to do so.  However, UHC's senior attorney is standing by this decision stating that MPPR is the norm and that UHC doesn't expect their member's to pay the difference when reducing a provider's/facility's billed charges when applying MPPR because it is widely accepted as the norm.

I am aware that MPRR is common these days.  However, I don't think the norm is 100-25-10.  And, I am sure that the provider's/facilities still have right to balance bill the patient when there is no contract with the insurer/payer.

I was hoping someone could tell me if they have seen this done before and how they handled it.  Also, has anyone seen MPPR rates at 100-25-10 or is 100-50 the norm?

kristin

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Re: Improper multiple procedure reductions.
« Reply #7 on: October 23, 2015, 10:01:51 PM »
So when you say the billing is from the ASC, do you mean that it is the facility billing? Meaning it is NOT what the provider billed on their end, but what the ASC billed for the use of their facility? If the billing you posted is from the provider end, then that is a whole different issue, which I won't go into now, but there are problems o'plenty if it is.

Here is one of the issues for me, and while it doesn't answer your questions directly, I think it has some bearing on the situation...I can see from what was billed that the patient had surgery done on both feet. I bill exclusively for podiatrists, so I realized right away what was being billed from the codes, I bill them all the time. I also know that if the patient was having the surgery done in an ASC, that you can pretty much be sure this was elective surgery. So why would a patient choose to have elective surgery done at an ASC that is OON for them(with an OON surgeon, to boot), if they knew that the ASC would be submitting charges that totaled $32,000, and that they would be expected to pay ALL of that, if no repricing had been done? Or if after the repricing was done, and UHC hadn't told the facility to not bill the patient, that the patient would be on the hook for $23,000? I can see a patient wanting a specific surgeon to work on them, and understanding that the surgeon is OON, and being willing to pay for that OOP, but I can't see someone having that surgery done at an OON facility, knowing that they would be hit with such a huge bill. Something about that just doesn't sit right with me. Was the patient aware of what they may be liable for? Did the facility agree to giving them a discount, for choosing to have surgery at an OON facility? This is what is running through my mind, as I try to take the billing you posted in, because it is a doozy of a billing.  :D

While I agree fully that providers/facilities have the right to balance bill a patient that is OON, I also think that what the patients are being billed should be reasonable and customary, and let me tell you...those charges/prices you posted from the ASC are not reasonable and customary. I know you said that you are not a biller, and don't know anything about billing and coding, so from your perspective, you may be looking at the billing and are shocked at how low the payment was, versus what was billed. But what was billed is outrageously high, and should definitely be taken into consideration as you proceed with your appeal.

Take the 64450 charge for $1458.70, for example. That is a nerve block/local anesthetic injection. Average cost for syringe/anesthetic for that is about $10. But they billed $1458.70, and were repriced to $104.99. So they made almost ten times what it cost them to provide the supplies for the injection. Yet the patient should be billed the remainder of $1353.71? Or rather $2707.42, since there were two injections? Even if I factor in the labor cost of someone filling the syringe, which takes less than a minute, the ASC still made great money with the payment of $104.99 per injection. How the patient could then have been billed that $2707.42 had the claim not been repriced is beyond me.

While I am all about providers/facilities/hospitals/ etc. getting paid what is fair and reasonable from insurance companies, and I fight every day to make sure the doctors I bill for are fairly reimbursed, I can also see when what is being billed isn't reasonable, and that the payment is fair, or more than fair. In this case, what the ASC was repriced to is more than fair in my opinion. Certainly, you can appeal what UHC has told the patient, so that you can bill the patient the $23,000, but if I was the patient, I would have my attorney at the ready, and would argue that the ASC was massively over billing their charges, and rightfully so.

I know that I haven't answered your questions about how UHC did their MPRR, or if what UHC is saying to the patient is legal or not, so here is what I know:  MPRR that I have seen with most insurers is 100-50-25, and unless someone signs a repricing agreement that says they won't balance bill the patient, then they can do so. All of this said, I would proceed very carefully here. I am getting major warning bells sounding off from the billing you posted, and would not want you to step into a fight for something that isn't warranted. My opinion is that what the ASC has been paid is more than fair, they should be happy with what they got, end of the story. I personally would not pursue this any further if I were you, but that is just my take on it.

I certainly hope for other opinions on what I have said in this post. I am looking at this as not only a biller, but also as a patient, and trying to balance the two perspectives. In this particular situation, I have to side with what the insurance company has decided is fair reimbursement for the services provided, others may disagree.

Questhrr.com

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Re: Improper multiple procedure reductions.
« Reply #8 on: October 24, 2015, 09:56:25 AM »
Hello Kristin,

Thank you soooooo much for your input.  Actually, you may have answered my questions (concerns) in a better way than what I have been asking for.

As I mentioned, I don't know anything about the billing and coding side of things.  I too am all for both the providers and the patients.  However, since I work for providers, I take their word when they tell me that they have been underpaid.  I wasn't at all sure about this particular claim, I just knew that a payer cannot "reprice" a bill and write off the remaining charges without a contract agreement with the provider.

Regarding this bill from my client, they are neither the ASC or the provider.  They are a development, management, consulting and billing company for free-standing outpatient surgical facilities, office-based surgical programs and healthcare entities.  They provide a program for physician practices that perform surgical procedures in their offices.   And, they provide billing for facilities, so, that's pretty much why I say that it's an ASC billing.

What this client has explained to me is that they are not in contract with anyone, however, many of their patients MUST go to their facilities for different reasons.  Therefore, they always contact the payers for benefit verification and if the payer agrees to pay UCR rates, then they agree to take the patient.  They have told me that they rarely receive any payment from patients.  Thus, I'm guessing that when a payer pays anything short of UCR, they will bill the patient ONLY the unpaid UCR rated balance.

They informed me that their billing methodology is always 300% Medicare Rates across the board.  So, I'm not sure how this would make the charges exorbitant as you mention here.  Howbeit, if what you're saying about these charges being exorbitant is true, then it would seem that the only unfairness about the payment is that they were reduced at 100-25-10 as apposed to the norm of 100-50-25.  Would I be correct in this assumption?  Also, does anyone else agree that these charges are exorbitant?

kristin

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Re: Improper multiple procedure reductions.
« Reply #9 on: October 24, 2015, 11:57:09 AM »
Hello Kevin-

Yes, you are correct in your assumption that I find their MMPR incorrect, I have never seen it done the way they did it. Doesn't mean others haven't, but I haven't. I am wondering if it has something to do with being OON...I only deal with PAR billings with my docs.

I did a little research on the fees charged after you said that the charged amounts they selected are based on 300% of Medicare rates. I looked at a few fee schedules for ASC Medicare rates(as opposed to physician rates, because we are dealing with the facility side), so as to find the highest rate I could for the 64450 code I talked about. That rate was $53.68. Let's round up to $55.00, for even numbers. That means they should have billed the 64450 at $165. But they billed it at $1458.70. Then I took one of the higher priced surgery codes, 28124, and ran that. ASC Medicare allowed is $307.38. Round up to $310, make it 300% of that, and you get $930. But they billed it at $7919.70.

This is why I think their charged amounts are way too high, but also why what they were paid is fair to me. They basically got double the Medicare allowed amount of the 64450, and waaayyyyy more than that on the 28124.

But I still want to know if others here agree that what they charged was exorbitant, because maybe it is just me. LOL! I do know I feel better that they only charge the UCR balance to patients.


Questhrr.com

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Re: Improper multiple procedure reductions.
« Reply #10 on: October 24, 2015, 12:44:40 PM »
Hello Kristin,

Again, thank you.

I have to admit that I'm a little perplexed at this whole issue because like you, when I look up those codes, I get prices wayyyy less than what they billed here. However, even though UHC paid $104.99 for code 64450, per their repricing sheet, that's 10% of UCR which means they consider UCR for this code to be $1,089.90 instead of the billed amount of $1,458.70.  And, when viewing other EOB's for this client, Cigna paid an allowed amount of $728.83 for the same code and Aetna allowed the entire amount billed.

So, I must really be missing something.  I cannot figure out how they come to these rates, but it seems that payers are considering these rates at just under UCR.

Could it be that they are figuring in billing for both provider and facility?  I'm just guessing because as I said, I know nothing about coding and billing.  But even though I cannot generate amounts close to theirs, they claim that its at 300% of Medicare and the EOBs I get for this client shows that other payers are paying just under their billed amounts.

I'm really confused!!!!!!

kristin

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Re: Improper multiple procedure reductions.
« Reply #11 on: October 24, 2015, 07:35:40 PM »
I am just as confused as you! Even if it was both provider and ASC payments in one, the provider allowed amounts are not that much greater with Medicare than the ASC ones. Because I have zero experience in billing ASC, I have to be missing something here, but I don't know what.

Questhrr.com

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Re: Improper multiple procedure reductions.
« Reply #12 on: October 25, 2015, 02:42:39 PM »
Well thank you anyway for your input and honest answers.  :)

Michele

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Re: Improper multiple procedure reductions.
« Reply #13 on: October 26, 2015, 09:24:04 AM »
Wow kristen!  Great info.  I totally missed that it was the ASC and the amounts do indicate that.  I just got caught up in UHCs response.  I agree that even if the provider is out of network the patient should not be charged excessively.  I'm curious as to why a patient would agree to go to an ASC that did not accept their insurance.  Anyway, thanks for sharing such good info.  We used to bill podiatry but haven't for a few years now.
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kristin

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Re: Improper multiple procedure reductions.
« Reply #14 on: October 26, 2015, 06:51:36 PM »
Thanks, Michele!  :D