Your steps in fighting for your claim could make or mar your practice's chance for a fair reimbursement.
Sometimes you may be in a situation where you wanted to contest a denial by an insurance company based on irrational payer guidelines. There's no doubt that it may seem like trying to break down a stone wall, however you are not helpless to change the situation to your favor.
As such what can you do here? Your steps in fighting for your claim could make or mar your practice's chance for a fair reimbursement. But then the insurance company can set any rules it wants and you are forced to play by them when your doctors sign the contracts. Nevertheless, you can still walk past the barriers by following these tactics.
The first and foremost thing you need to do is to get a copy of your contract and see what degree of latitude your payer can take relative to AMA and CMS coding rules. If the insurer is violating what's set forth in the contract, use the contract in your appeal to fight this arbitrary policy and get it overturned.
If the contract is silent on this or allows such arbitrary use of rules in favor of the payer, you should gear up to drop the payer as one of your participating payers. Do not get jittery – be all set to drop them in this stage.
Third, conduct a meeting between your physicians and the medical director. Enquire the medical director to justify this policy in clinical terms as to why the insurer doesn't reimburse a physician for the diagnostic colonoscopy and the removal of polyps when you apply modifier 59 (Distinct procedural service) to indicate different sites. Enlighten on the fact that breaking the colonoscopy and the biopsy into multiple sessions will make the payer incur multiple facility fees, multiple anesthesia sessions as well as the physician professional fees.
As such what can you do here? Your steps in fighting for your claim could make or mar your practice's chance for a fair reimbursement. But then the insurance company can set any rules it wants and you are forced to play by them when your doctors sign the contracts. Nevertheless, you can still walk past the barriers by following these tactics.
The first and foremost thing you need to do is to get a copy of your contract and see what degree of latitude your payer can take relative to AMA and CMS coding rules. If the insurer is violating what's set forth in the contract, use the contract in your appeal to fight this arbitrary policy and get it overturned.
If the contract is silent on this or allows such arbitrary use of rules in favor of the payer, you should gear up to drop the payer as one of your participating payers. Do not get jittery – be all set to drop them in this stage.
Third, conduct a meeting between your physicians and the medical director. Enquire the medical director to justify this policy in clinical terms as to why the insurer doesn't reimburse a physician for the diagnostic colonoscopy and the removal of polyps when you apply modifier 59 (Distinct procedural service) to indicate different sites. Enlighten on the fact that breaking the colonoscopy and the biopsy into multiple sessions will make the payer incur multiple facility fees, multiple anesthesia sessions as well as the physician professional fees.
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