Payments > Insurance Payments

Insurance company reducing/denying payment.

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dekenn:
Really? How do you bill it? I was taught to bill separate lines with RT and LT modifiers. If he takes 3 views of the right and 3 views of the left foot, I would bill
73630 RT
73630 LT

Merry:
I just did a search and it looks like it depends on the carrier. And some require a -50 modifier. Some require two lines with a RT and a LT for each line item.

kristin:
For the MAC's I bill for(NGS, FSCO, Novitas, Cahaba), and all the commercial insurances I bill for in Illinois, Georgia, Florida, and Pennsylvania, they want bilateral x-rays billed on two lines, with the RT/LT modifier. None of them apply a discount on the second set of x-rays.

It sounds like Magnacare is considering an x-ray to be a procedure, when it is not, it is a diagnostic exam, if you will, and in a totally separate category for reimbursement.

dekenn:
Ok, I think I have some ideas about appealing the x-ray reduction.
Any input on how to appeal the casting material being a write-off? Ideally, I'd like to convince the insurance companies to pay it, but will settle for them making it a non-covered service that is patient responsibility.
Anyone have any experience with cast materials?
Thanks

Rclausing:
"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?"

As stated, these are diagnostic tests, not procedures so shouldn't be subjected to the multiple procedure rule. And I would appeal on those grounds. While you're at it, see if you can get a hold of a provider representative that is responsible for contracting, credentialing etc. You'll need to check your contract and verify there isn't something in their reimbursement policy that describe your situation. It may be you have a contractual obligation to accept these terms (seems unlikely). One thing you want to look for is any reference to the Correct Coding Initiative. If it is stated in your contract that they follow the CCI edits, then they are contractually obligated to allow 100% for the second diagnostic. A provider rep (if they have them), can assist you in getting your denied claims paid, and help prevent future denials - if applicable.

Ultimately, if you choose to play hardball as a last resort, you can try to convince them that processing claims outside of the CCI rules constitutes fraud under 18 U.S. Code § 1035 - False statements relating to health care matters:

(a) Whoever, in any matter involving a health care benefit program, knowingly and willfully—
(1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; or
(2) makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any materially false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry,
in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 5 years, or both.
(b) As used in this section, the term “health care benefit program” has the meaning given such term in section 24 (b) of this title.

I've used this before in appeals where an insurance co. was inappropriately bundling surgical procedures, and the physician was ready to take them to court over the situation. In that instance, we got a large check from them reprocessing claims. And it arrived within 7 days.  ;D   Ah, the joys of Claim Check.   >:(

Ancillary medical materials are almost always bundled into the associated procedure. I'm surprised anyone pays for the casting plaster. If you are using some special material that could be considered outside the scope of a normal cast, some sort of ABN might be in order so that the patients are aware that it will be their responsibility and/or have a choice of using something else.

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