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Improper multiple procedure reductions.

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Questhrr.com:
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

Michele:

--- Quote from: Questhrr.com on October 23, 2015, 09:43:40 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.



--- End quote ---

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.

Questhrr.com:
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:
I have a question...is that billing what the surgeon billed, or what the ASC billed for their portion?

Questhrr.com:
I'm not sure.  I just know that the billing is from the biller for the ASC.

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