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Thread: Changing Billing Number to Fit Insurence

  1. #1
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    Confused Changing Billing Number to Fit Insurence

    Hi All,

    I am no fan of insurance companies (or medicare for that matter) but have seen a practice done that seems at best unethical and at worst illegal. When patients come in for cataract surgery evaluations or even simple glaucoma checks the doc fills out the billing form and submits it to the billing dept. If the insurance company will not cover the procedure/exam billing sends it back to the doctor to determine if another code is more appropriate (i.e. a code that insurance will cover)

    Shouldn't the billing code be whatever was determined during the exam? It is done at many of the companies I have seen in my area and I can not imagine the insurance companies would appreciate it...changing the code to something similar so that it will be covered...

    Does this happen often?



    .

  2. #2
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    Actually today we have a situation where survival appearently is determined by a battle between insurance companies finding excuses on how to reject claims and providers attempting to find a way to around the rejections.
    I have been told that in our state BC/BS does not even consider a claim until the third time it is submitted and subsists on not paying those claims that provider gives up on during this re-submission process.
    We have different providers requireing different codes for the same proceedure.
    Some insists on CPT others on V-Codes all in an attempt to make what precious little insurance the patient has useless.

    I am not siding with either the provider or insurance company but the situation is a mess and another thing that should be given a firm hand by state insureance commissioners, legislatures or the courts or someone.

    Chip

  3. #3
    Master OptiBoarder
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    We have never had an issue with procedures being denied unless the coding was wrong in the first place. BCBS pays quickly here with no rebills needed. It really depends what the patient presented as the problem that determines the diag code doesn't it? "Finding" a code to bill that is other than the presenting problem would be illegal I would think. If the code is correct and the insurance denies for some reason (shouldn't you know ahead of time?) then you bill the patient just like my doctor or dentist bills me when a procedure isn't covered.

  4. #4
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    Here if you can find a "willing" BCBS agent, they will tell you what you did wrong on the first submission (most will not) then you can re-submit with all the t's crossed, the i's dotted just as instructed and they will reject it because you did what they said to do.

    Chip

    Another related pearl, until recently workmen's comp paid full fee quick, no questions (if patient was qualified). Now they just paid me $300.00 of a $1998.00 fee for a custom prosthetic eye.
    I asked an ophthalmologist friend about this and he told me this had recently been changed because the orthopedic surgeons had been charging fees in excess of $100,000.00 for proceedures that would have been $10 or $20,000. It gets worse if I bill workmen's comp (and in some circumstances any third party) I have to accept whatever they paid, can't charge the patient anything and cannot even reveal to the patient the chincy fee they paid. They don't want the poor "covered" patient to realize how lousy his coverage is (or be able to complain to any authorities about it).
    This may be coming to third party "payers" near you.

    Chip

    Now Workman's comp patients are SOL and must go out of state (as I am the only in-state provder). I am not doing work that takes this many hours for this fee.


    Chip

  5. #5
    Rising Star OptiBoard Silver Supporter
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    Techgeek,

    There is also the situation that you may run in to where many vision plans improperly utilize the 920xx codes, apparently because this is always how its been done. Its hard to call it anything other than fraudulent, but its allowed to continue.

    So, the providers are put in a position of improperly coding so that the vision plans get the numbers they want and will actually pay.

    Another situation occurs with medical insurances. Often, you fill in hundreds of letters and numbers for each claim you submit. If you are off on one of them the entire claim is denied. A sane person would not think this is fair but its allowed to happen. Can you imagine this happening in another industry and having those companies survive?

    Another (probably what you are referring to) situation occurs where each local region determines their own silly rules. You may be the best coder in the world but if they change their minds on something for virtually whatever reason they can come up with, you won't be paid.

    Perhaps there are those providers who improperly code for extra profit, but unfortunately the current system seems to be set up to assume all providers are criminals (and also allows the most profits for the insurance companies, how convenient).

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