Payments > Insurance Payments

Billing provisional and/or rule out diagnoses

(1/2) > >>

Sophrosyne:
One of my therapists is wondering if she can bill provisional and/or rule out diagnoses. We don't want to wait until testing is done and a final diagnosis given to bill insurance. Is there a particular format for this on the claim form? I've seen doctors write out "PROV314.01" or "R/O314.01"; is this how you'd enter it on the claim?
Thanks guys... I don't know what I'd do without you!!!  :D

PMRNC:
I'd say NO. Many carriers won't even cover ADD. The tests are not even conclusive really just yet. What exactly are you looking to bill that is outside the testing services??

Sophrosyne:
The ADD diagnosis was just an example. I don't have an actual provisional diagnosis as of yet. I was just wondering if it was even possible to bill a provisional or rule out diagnosis to an insurance company. And if so, if there is a particular format for it?
The basic issue is this. The therapist wants to try to file with insurance after each testing session to see if it will be covered by the insurance company. She doesn't want to risk waiting until the testing is done only to find that insurance doesn't cover and the patient is stuck with a huge bill (which may or may not get paid). I'm not sure if this is even possible--maybe there's nothing to be done to mitigate the risk, except call in/go online and try to see if there are any limitations or exclusions on the policy.

RichardP:
The first line of responsibility is the patient.  They should be the ones checking with their insurance to see if a desired procedure is covered.

As a service to their patients, the staff of some doctor offices will check with the patient's insurance to see if the procedure is covered.  But, ultimately, it is the patient's responsibility to know what their insurance will pay for.

As for your billing question - do you understand how many kinds of illegal it is to bill for services that have not been provided?  That, in essence, is what you are wanting to do.

Unfortunately, many insurance carriers won't give you a straight answer about whether something is covered.  You may have to just do, bill for it, and see what gets paid.  And what gets paid will vary, depending on the insurance carrier, and any given plan within an insurance carrier.

PMRNC:

--- Quote ---As for your billing question - do you understand how many kinds of illegal it is to bill for services that have not been provided?  That, in essence, is what you are wanting to do.
--- End quote ---

I have to agree, basically the therapist is wanting to submit testing and "see if insurance will pay". If the psych testing codes are authorized you can check with carrier when you verify benefits. There's not too many "rule out" diagnosis codes you can use in Mental health.. no such thing as "rule out depression", "rule out bipolar disorder etc."  The tests should be medically necessary and documentation in the patient's chart needs to reflect services rendered and diagnosis presenting. It is NOT usual for a therapist to go testing w/out seeing the patient to make initial assessment.   

Navigation

[0] Message Index

[#] Next page

Go to full version