Out of Network Providers

[cflorez]

I am a medical biller and I have questions regarding appeals for our of network provider.  I have a provider who's claim was paid but for only 1 unit when there were two line items with 2 units. I verified the allowed amount and that what was paid to the provider, but not for the second unit. I appealed the claim twice and they gave me the same answer. It was paid correctly but don't address the units. I have spoken to a claims supervisor about 6 times.(different supervisors) and each one states they will investigate it and never call me back.  I have called the Anthem Network Provider relations Rep but they wont help me because the provider is out of network.  Can anyone help me or maybe explain to me what is happening.

[kristin]

In order to better answer your question, it would help to know exactly how the claim was billed/what it was for. There are instances where regardless of par status, certain CPT codes can't be billed with more than one unit, or need 50 a modifier instead, etc. So if you could provide a detailed listing of what exactly was billed, that would really help.

[cflorez]

Yes Of Course. I billed BXBS for Oral surgery codes. Anthem here in California. Code 21208 Paid for one unit $655.88 (Allowed amt should be $755.13.but I billed for 2 units. Code 21248 Paid for one unit at $653.08 but billed for 4 units, Allowed amount is $653.08. I Should have billed for one unit of code 21249.
Code 21215 Allowed amount is $3319.00 was paid $323.75 for one unit. But I billed for 2 units. I obtained a pre authorization in which I sent in detailed soap notes on the visit and treatment plan with Medical Necessity. It was approved. The authorization indicated the units as I requested and billed.   As I stated I spoke to many supervisors but cant get an answer from anyone.  I was able to verify the allowed amounts through the claims department.

[kristin]

Let me preface this by saying I know nothing about billing oral surgery codes, but certain rules apply regardless of the codes being billed. I did look up each code description, and I *think* your issue may be that these are codes that cannot be billed with units. Even though that is how you pre-authed them. You need to check the NCCI/CCI edits on these codes, and see if they are allowed to be billed with as many units as you billed them with, OR, if you should have billed some of them with 50 modifiers if they were done bilaterally, or with 59 modifiers if they were NOT done bilaterally, but were done on separate sites on the jaw. Check the MUE also, because that will tell you how many units can be billed per session/encounter, and if you have gone over the MUE unit amount for a CPT code, you need to appeal with notes showing why it was gone over.

[cflorez]

Your response stuck a cord in me. I then went in research of an answer in a different way. They were pre authorized as 21208 2 units, 21215 2 units. For 2 separate dos services. Totaling 4 units on each code. It was approved that way. (I learned later that that authorization is meaningless) The patient wanted it all done in one day since he was going out of town. I called Anthem BXBS and asked if that would cause a problem, they indicated no. They stated just bill total number of units. However, it does cause a problem.   It doesn't matter if I bill one line item with 21208 with no modifier and the other line item as  21208 with 50 modifier. To indicate 2 separate procedures on opposing structures. They will not accept it that way. Anthem states that if I bill that way they will convert to one line item only and pay the allowed amount for one unit. That is how they pay. Maximum allowed amount is only for one unit.  That is why my 3 appeals came back as paid correctly and I stated your not addressing the units. They were because they only pay one unit. regardless. So for them to state I can bill for 2 dos and combine to one was hugely  incorrect. What end up happening is that the doctor is only really getting 1/4 of the overall bill. Outrageous. Aetna, Humana, Medicare do not pay this way. So from now on with Anthem bxbs patients,  we do not combine units billed. The doctor will work on one quad at a time and bill one quad at a time. Here is the reimbursement policy f anyone wants to read it. https://www11.anthem.com/provider/noapplication/f0/s0/t0/pw_g313750.pdf?refer=ahpmedprovider&state=mo

[Michele]

Thanks for sharing your final outcome.