Have you ever wondered why sometimes the insurance company "has changed the code to a more appropriate payment code" when you get a claim for reimbursement? You filed your claim in the form of 99214, but they paid you 99,132 or even worse, 99,212. This practice is called downsizing.
Do you have to accept it? Then in some cases you will do this. A lot will depend on your contract with the insurance company. Some contracts only allow providers to bill certain cpt codes. In this case, they can change the billing code to one of the allowed codes. Or the contract can specify that you can only bill a specific number of higher codes or a percentage of claims.
But sometimes, the insurance company will only underline your claim, which is not due to contract specifications. In this case, you can appeal. We recently claimed that the insurance company lowered the 99,214 to 99,213 and told us that they only allow service providers to charge 99,214 patients every six weeks. That is ridiculous. How does the guide apply to any patient?
Sometimes we only need to remind the insurance company that the doctor is the one who determines the patient's needs. In this case, we sent an office note and a letter informing them that we were appealing the processing of the claim. Doctors have already met the requirements for billing for 99214, and their "guide" is not appropriate. We received the difference payment after 10 days.
Therefore, if there is a problem with your claim and these claims do not meet the contract specifications, you should appeal. Don't just accept what the insurance company does. This is what they depend on. Imagine how much they saved on a vendor that didn't take any action.
Copyright 2008 - Michele Redmond
Orignal From: Insurance company code to prevent medical claims
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