Author Topic: Denial code CO-45 from BCBS when not contracted  (Read 1668 times)

Glamador

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Denial code CO-45 from BCBS when not contracted
« on: March 28, 2016, 10:33:46 AM »
Hello,

I am a refunds reviewer for a municipality in Florida that provides ambulance services.  I have no training and only limited experience reviewing EOB codes, so please excuse any ignorance on my part.  I am trying to do my due diligence in this matter.

I am seeing Blue Cross Blue Shield (BCBS) listing code CO-45 as a contractual obligation asserting that the remaining balance cannot be billed to the patient.  However, we have no contract or agreement of any kind with BCBS as a medical care provider.  As such, I do not know the basis for the charges that they are demanding we write off.  No other commercial insurance provider that I have reviewed cites that denial code in this manner.  The only insurer that write-offs apply to, to my knowledge, is Medicare.

Now our billing company has processed a refund for the non-allowable amount to other parties that have already paid.  Why is this the appropriate action?  What right does BCBS have to dictate what we charge to patients when we are under no obligation to them in any way?

The billing company has cited a Florida Personal Injury Protection (PIP) law [Title XXXVII, Chapter 627.736 (5)(a)1], as justification for obeisance with the proposed write-off, which indicates that insurers can limit reimbursement to 80% of 200% of Medicare allowable or 80% of worker's comp allowance.  Sub-paragraph 4 further indicates that the patient cannot be billed in excess of that 80% limit.

Now, I am neither a billing expert nor a legal expert, and I do not trust our billing provider to know any more than I do, so I am asking here whether this is on the up-and-up.  On common sense grounds, this seems ludicrous.  From the interpretation I've been provided I cannot help but wonder why we even attempt to bill more than 80% of those restrictions if it seems like anybody, be it Medicare, Commercial, or Worker's Compensation insurers can just...deny anything above that.  It seems insane.

Sriram_Sub

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Re: Denial code CO-45 from BCBS when not contracted
« Reply #1 on: March 29, 2016, 09:28:09 AM »
I guess someone has to talk to the provider relations at BCBS of FL and discuss about this using a sample claim.
Sriram

kristin

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Re: Denial code CO-45 from BCBS when not contracted
« Reply #2 on: March 29, 2016, 09:21:53 PM »
This subject has been discussed in other posts here, you may want to use the search function and the term "usual and customary", and you will see what has previously been discussed. That said, here are a few things to consider:

1. Just because a provider of services is non-participating, or out of network, or has no contract with an insurance company does not mean that they can charge whatever amount they want, and that they will receive that amount from the patient's out of network benefits, and/or the patient. All insurance companies have a "usual and customary" or "reasonable and customary" allowance for every charge a provider of service will bill. Think of it this way...why would any provider of service contract with any insurance company, if they could just bill whatever amount they wanted for a service, and actually receive that amount in full, between the insurance company and the patient? While insurance companies may allow a bit more for services provided by an out of network provider in some cases, thus making the patient pay more out of pocket, in no way are they just going to allow the full amount if it exceeds their U&C or R&C amount.

2. Insurance policies have in network and out of network benefit levels. As an example, if I see an in network provider, I have a $250 deductible, and insurance pays 90% of U&C charges after that, and I pay 10%. If I see an out of network provider, I have a $250 deductible, and insurance pays 70% of the U&C charges after that, and I pay 30%. Either way, the charges are subjected to U&C rates. One reason for this is so that the patient, who may not always have a choice of seeing an in network provider, is not slammed with ridiculous bills(which could literally result in collections/bankruptcy proceedings). You said on common sense grounds it seems ludicrous/insane that insurance can do this...but think about it this way, if there were no U&C rules:

You are in a car accident, and need emergency surgery. You are transported unconscious to the nearest ER, and surgery is done. The surgeon happens to be in network with your insurance, as is the hospital, but the anesthesiologist is out of network with your insurance. You don't know this, because you are unconscious, and don't exactly have a choice in the matter. That out of network provider charges $10,000. If they were in network, they would get $5,000 from your insurance, let's say, and have to write off the rest, you get billed nothing, because you have 100% coverage for in network benefits. But since they are out of network, you get billed the full $10,000. How is it fair that you have to pay the full amount of what they billed, when you didn't have a choice in what provider took care of you? But because of U&C, you are only liable for $5000, and your out of network benefits will pay a portion of that. Much better resolution for you, and frankly, what I feel is fair, IMHO.

3. Why providers of service attempt to charge WAY beyond what is "reasonable" is a mystery to me. Fee schedules are set using various methods, and a common one is to take the Medicare allowable, and add a set percentage on to that, and make that the fee. I had a doctor bill my insurance(which has one of the highest fee schedules), $500 for a 99203. The most any insurance I know allows for that code is around $150. So why charge way beyond that? If it was to "sticker shock" the patient, it worked. I won't go to that doctor again. Even though I didn't have to pay anything beyond my co-pay, I don't appreciate the inflated charge.

4. You say you deal with ambulance services. Are the patients transported in these ambulances given a choice to choose an ambulance company that is in network with their insurances or not? Are they even aware that they are in an ambulance that isn't contracted with their insurance(elderly, unconscious, etc)? If not, you can see where all of the above I have mentioned comes into play. Given a choice, most people will choose a provider in their insurance. If that choice is not available, or not explained...that is a different matter.

For someone new to all of this, as you say you are, I can see where it doesn't make sense about the refund that was done. Hopefully, what I have said here will make it a little more understandable.

Sriram_Sub

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Re: Denial code CO-45 from BCBS when not contracted
« Reply #3 on: March 30, 2016, 05:20:16 AM »
Very detailed explanation, Kristin! Thank you.
Sriram

Glamador

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Re: Denial code CO-45 from BCBS when not contracted
« Reply #4 on: March 30, 2016, 09:13:36 AM »
This subject has been discussed in other posts here, you may want to use the search function and the term "usual and customary", and you will see what has previously been discussed. That said, here are a few things to consider:

I searched and read quite a few topics using the keywords "CO-45" and "Balance Billing".  None of those threads spoke to my issue exactly, which is how an out-of-network (we have no network or contracts with anyone) can cite a contractual obligation that does not exist.

As a reviewer, it is my job to make sure that A) we actually received the original funds, and B) that each payment, charge, or adjustment that makes up the patient's balance, positive or negative, can be supported.  Documentation analysis is my primary role.  And as we have no fee schedule or relationship with BCBS, the justification for the specific amount of these write-offs is unclear.  Unclear is a no-no.

2. Insurance policies have in network and out of network benefit levels. As an example, if I see an in network provider, I have a $250 deductible, and insurance pays 90% of U&C charges after that, and I pay 10%. If I see an out of network provider, I have a $250 deductible, and insurance pays 70% of the U&C charges after that, and I pay 30%. Either way, the charges are subjected to U&C rates.

This would make some kind of sense if we did not regularly and customarily receive payment in full, either from an insurance company (usually casualty/liability) or in combination with patient payments.  In fact, looking at a trip from a mere two months ago, I see we received in excess of 85% from BCBS with the remaining amount paid by the patient.  No denial code was even claimed.  I don't like that kind of inconsistency.

As I alluded to in my original post, the only insurer for which we regularly write-off charges is Medicare (or Medicare replacements subject to the same treatment) themselves.

For someone new to all of this, as you say you are, I can see where it doesn't make sense about the refund that was done. Hopefully, what I have said here will make it a little more understandable.

What gets my goat is this sub-paragraph that says private companies can limit to 80% of even what the government pays.

I am familiar with the concept of Usual & Customary.  But I had always understood it as a way for insurers to justify not paying more than a certain amount.  I thought it was a way to screw over their customers, as I would expect them to.  I would never have imagined that they could use that justification to force a fee schedule onto providers that never had a chance to negotiate it.  And it strikes me as unjustified that a Usual & Customary (term) amount could be below what we usually and customarily (literal) receive in payment.