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Insurance company reducing/denying payment.

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dekenn:
Hello All,
I have two issues that I've been trying to get resolved and I'd like to know if anyone out there is having the same issue, and if so, how did you go about appealing them, and were you successful?

Issue 1: One of the insurance companies we deal with (Magnacare) is reducing the payment of x-rays by 50% when x-rays are taken bilaterally. They pay 100% for the first foot, then reduce the payment for the second foot, stating that it's a "secondary procedure/reduction in allowance". I've tried calling, and they state "that's our policy", however, nothing is every forthcoming in writing. Is there some way I can appeal this?

Issue 2: I have two different insurance companies that won't allow any payment for cast materials when billing for the application of a cast. I have appealed both to both of these companies with printouts from various websites showing that cast materials are billable separately. Again, neither company can give me this in writing specifically, just "it's not a covered benefit". Now, I understand that some of the policies don't cover any DME and will not cover this, but then shouldn't it be patient responsibility? Why is it that the doctor doesn't get paid at all for this? They refused to reprocess the claims showing that it's patient responsibility. Again, any suggestions on how to approach this?

Thank you all so much for any advice/input!

PMRNC:
Before getting specific..

Do you have a contract with the carriers? If so have you looked at those first?

2nd.. if these are ERISA based claims do you have copy of the plan benefit summary?

Merry:
I have never seen bilateral x-rays paid any other way. They even will do that with an MRI of 2 different body parts on the same day when done in a medical office. When performed in a hospital based radiology practice reimbursement is different.
 

dekenn:
Yes, we are participating with all three insurances. None of them are government health insurance plans, they are all private employer plans, (Magnacare, Barnabas Health and Qualcare) Not sure what would make them ERISA plans? None of the "contracts" go into specifics about how different codes are paid. They pretty much state "according to our fee schedule". You can get the reimbursement rates by requesting certain codes, but they will not release the whole fee schedule. As far as the plan benefit summary, they won't release that either. The employee has to request it and if they want to, can let us see it.
As far as the cast supplies go, I have other insurance companies that don't pay it, or will only pay half, but they always show it as a non-covered benefit and patient responsibility.
As far as bilateral x-rays, this is the ONLY insurance company that does this! Medicare and Medicaid don't even cut the 2nd one by 50%.

Merry:
Interesting..I have my Medicare paperwork in front of me and they are not reimbursing 100% on a bilateral xray.

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