Avoid Down Coding By Insurance coverage Corporations On Healthcare Claims

Bridget J. Sims

At any time wonder why occasionally when you get reimbursed for a claim, the coverage corporation has “changed the code to a a lot more ideal code for payment”? You submitted the claim as a 99214 but they paid you for a 99213 or even worse, a 99212. This follow is named downcoding.

Do you have to acknowledge it? Very well in some conditions you do. A good deal will count on the deal that you have with the coverage carrier. Some contracts will only allow for vendors to monthly bill particular cpt codes. In that scenario, they can change a billed code to just one of the allowed codes. Or the contract may specify that you can only monthly bill a sure quantity, or percentage of promises at the increased codes.

But from time to time an insurance policy provider will just downcode your assert and it is not because of to agreement specs. In that situation you can charm it. We just lately had a assert that the insurance policy carrier downcoded a 99214 to a 99213 and explained to us that they only permit a service provider to bill a 99214 each and every 6 months for a individual. That is ludicrous. How can that guideline apply to any patient?

In some cases we just have to remind the insurance policies carriers that the physicians are the kinds who ascertain the patient’s wants. In this circumstance we despatched in office environment notes and a letter advising them that we had been desirable the processing of the assert. The medical professional had achieved the requirements to justify the billing of a 99214 and their “tips” had been inappropriate. We acquired payment for the difference about 10 times afterwards.

So if you are owning issues with your promises becoming downcoded, and they are not owing to contract specifications, you ought to attractiveness. Do not just acknowledge what the insurance policy carrier does. That is what they are counting on. Just think of how considerably funds they help you save on the vendors that do not do something about it.

Copyright 2008 – Michele Redmond

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