During a bene the benerep asked me, “Why is the patient being seen?” In the absence of a patient encounter I replied, “Duno?” The benerep went on further to explain and emphasize the point that many claims get rejected because the patients are not being seen for an illness or injury. I noted this on the form and sent it to the provider.
A day later I have a patient encounter and submit a claim using valid dx codes for back pain and neck pain. I track the claim and everything seems to be going well until I am told the claim has been “sent for repricing” (Is repricing even a word?). In the next follow-up I am told the provider has been notified to give additional information to determine if the patient was seen for an illness or injury. Upon reporting this information to the provider, albeit the hour was well into beer thirty, a sort of panic mode kicks in and I receive a rapid reply asking, “What is an injury? What is an illness? What do they mean?”
My question is twofold. First, how do I avoid getting into this awkward situation in the future? Should I make it a policy to always have the patient encounter in front of me during a bene? Second, how do proceed with the current predicament? Should I ask the insurance their definition of “illness or injury”? Or should I take a step back and look at the larger picture of medical necessity?