Medical Billing Forum
Billing => Billing => : WhitanyaS February 11, 2019, 06:17:03 PM
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Hello all,
I have received denials from FL Blue for outpatient detox for incorrect biling. They were initially billed on a HCFA with CPT code S9475. The payments were painfully low. As a project, I have been advised to rebill about $300k worth of claims on a UB-04 H0014/0944. They are denying to incorrect billing but i do not see any other codes I can use.
It facilities is a free-standing facility with Taxonomy 261QR0405X - Clinic/Center: Rehabilitation, Substance Use Disorder. Any advisement would be greatly appreciated.
Thank you,
Whitanya
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Are you billing for the facility charges or the professional fees? Are you credentialed with FL Blue as a facility?
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Good morning,
Thanks for responding!
We are credentialed as a facility with FL Blue and are billing per diem rates because of that (as opposed to ancillary professional services).
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If you are credentialed as a facility shouldn't you be billing on the UB04 at the per diem rates?
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Hello,
Yes, one think so but we are being told by FL blue the 0944 is not in their fee-shcedule and it, therefore, no payable. The only other possible codes to use (that i could find) is 0900, which is general behavioral health, and 0520, which is Free-standing clinic, general. Any thought?
Thanks
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Wow, that is crazy. 0944 is a very common rev code for addiction. And of course they refuse to tell you what you should be using in place of it.
You could use 0914 but that's not really the same thing. Can you bill it on the CMS 1500 with the H0014?
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Hi again,
Yes, 0944 is common op detox so we are stuck. 0914 is Individual Therapy; the medical records wouldn't pass review if we did and they were requested. I guess we could try the H-code on the 1500 but we are a facility and professional claims tend to get paid less. Any thoughts?
Thanks
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How are you credentialed with them? Them telling you it's not in their fee-schedule suggests to me maybe you are not credentialed properly? I would contact your provider rep, i wouldn't change the claim form and of course why should you take a big cut in reimbursement?
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Hello,
We are out of network.
Thanks,
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Well if you are out of network then it seems like it's the patient's issue. Maybe if the patient contacts them they will be more helpful. Obviously in this country D&A rehab is a common service so how 0944 is not in their fee schedule is beyond me. Are you filing as a courtesy to the patient?
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Hello again,
At capacity, we have 40+ clients rotating in and out so we always file claims as a courtesy to the client, lest we not get paid. Most of our clients are not up to the task of arguing with insurance companies, given their primary Dx.
Believe me, i agree with you; 0944 is a common service so how the heck can it not be on FL Blue fee schedule?! We are truly stumped... Thanks for all the responses!
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I wish I could think of something to advise you to do! :'(
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Well,
I tried. Thanks for the response.
Whitanya
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If you are out of network, they should be following U&C guidelines and DRG of course...If you have a "denial' you could appeal with description of the code attached. If this is an ERISA claim then you will need the patient to sign an ARF and then i would request from them complete documentation showing why that code is not payable. Even if claim is partially paid and with only that line item being denied, under ERISA it is an adverse benefit determination. Get the patient involved by signing an ARF (ONLY if ERISA). Your other option is to bill the patient and let them handle it.
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Hello,
Thanks for the response. There are several patients involved. I'll have to review to see which clients have ERISA plans.
Thanks again,
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The best solution is to credential with the carriers, especially with they type of services you provide. I'm thinking that getting upfront payment wouldn't work unless patients are getting grants directly from the govt/state.
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Hello,
Thanks for the input!
Whitanya