# BCBS Audit - Help Needed



## sknewhouse (Jan 11, 2017)

Does anybody have experience with Blue Cross Blue Shield auditing their claims?  We have been in a never-ending audit with BCBS of NJ (Horizon) since April of 2016.  They require that we mail (not fax or upload) medical records for any claim with a level 4 or higher E/M code as well as any claim with a modifier 25 or 59.  We are a dermatology practice and often perform multiple services at the same visit, so we end up sending records for most of our Horizon patients.  After that, Horizon comes back and either downcodes the E/M level or denies for invalid modifiers.

At first, this audit was legitimate.  Our former billing company never verified codes and often billed for services that were not rendered or diagnoses that were not accurate, so of course there were a lot of denials for medical necessity.  However, I have been doing all of the billing and coding since June of 2016.  The codes and modifiers are validated multiple times prior to BCBS receiving the claim.  Not only do I review all of the documentation before entering the codes, but I also run the claims through McKesson's Clear Claim Connection (per our Horizon rep's request) and let our billing system validate the claim before sending.  Horizon is claiming that we have a 100% error rate.  I didn't even know it was possible to have a 100% error rate, but that's what they're claiming.

It seems like this audit gets worse and worse as time goes on.  I'm now going back and forth on the same claim at least three times.  This is one message that they sent me today (99203):



> Originally declined X947: According to NCCI edits modifier 25 is not required.
> As per Horizon, E/M services performed on the same day as a procedure with a global surgery period of 000, 010, or 090 days is required to be significant and separately identifiable and should be billed with a modifier 25.



They have denied the claim both with and without modifier 25 attached to the E/M code.

In another case, when a patient with an extensive history of skin cancer had a full body skin examination with a biopsy performed at the same visit, they give this denial reason:



> Declined X947: A separate E/M is not supported, above and beyond the procedure being performed, and is NOT payable with the procedure billed.



Aside from the procedure performed, the notes show a detailed history, a sixteen-point examination, and moderate MDM.  We had billed 99214.  I wouldn't even have an issue with them downgrading to 99213.  But to completely disregard the provider's extra work is unacceptable.  No other payer is doing this to us.

A more recent issue is that now they are claiming that they never received records.  Each time they send a denial for missing medical records, I call provider services (as our rep told me she cannot do anything) and tell them that the records were already sent. Every time, they put me on hold for at least twenty minutes before coming back and saying that they do have the records and will reprocess again.

I have spoken with our rep, who does nothing but send me the same denial messages that I have on the EOBs and schedule phone calls with their audit team.  The audit team (a group of 4 CPCs) always says that I'm right and the claims are denying incorrectly, but they never do anything about it.  At this point, we're not really sure what to do.  I understand that the audit was legitimate at the beginning, but we are now going above and beyond what I think is reasonable.  There are claims going back to last April (some that are on their tenth round of edits) that they still haven't paid.  I have asked multiple times if there is someone above our rep that I can speak to, but I am always told that I am not to contact anybody else about this issue.

Does anybody have any suggestions?  Horizon makes up a good 25% or so of our patient base, so this is having a huge impact on the practice's finances.  At this point, we are well beyond NJ prompt pay regulations.  Do I contact the insurance commissioner?  Does that even do any good?  Is there anybody else I can contact?


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## jdibble (Jan 11, 2017)

Based on what you are saying this sounds like some type of harassment!  Where I worked previously we dealt with Horizon BCBS and they were hard to work with. Our hospital actually dropped their participation with them - and they were located in NJ. They only resumed a contract with them when we merged with a larger hospital system in NJ who had more pull as Horizon would lose a lot of money if they lost their contract with them. All of our doctors charges were under 100% internal audit before being released (and none of them ever had a 100% error rate!) and we did not get any rejections for 25, 57 or 59 modifiers applied correctly. 

I know it would be another expense, but have you had an outside auditor look at your charts to see if there is some documentation issues or to verify the correct use of the 25 modifier? I would have someone audit your charts and claims and if they agree with your coding I would contact the insurance commissioner to look into your problem with Horizon.

Hope you can get this figured out!


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## thomas7331 (Jan 11, 2017)

Going to your rep is always the best first step, but you might want to try leaning on them a little harder.  Have your practice administrators or any of the physicians gotten involved, or your practice's lawyers?  Going to your state insurance commissioner is sometimes effective, but be aware that they only have jurisdiction over fully insured plans in the state and a lot of commercial insurance patients fall outside of that.  If all else fails, your practice really should assess the cost vs. benefit of staying contracted with this payer and plan a strategy.  In my experience, a formal letter giving notice that you intend to cancel your contract is one sure way to get a plan's attention.  If your specialty is hard to find in their network and you threaten to leave, they will work harder to keep you in and meet your demands, but if they have plenty of providers already, you may not have that leverage.  If you have a lot of loyal patients who want to keep your doctors in their network, that could work to your advantage also.  There are some good resources out there on negotiation strategies with health plans that you can search for and it's also a topic that is presented frequently at conferences and seminars.  Not sure if any of these ideas help - it's not an easy situation you're in.


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## ljstoker (Jan 11, 2017)

*Good Luck*

I am also a dermatology office and I have never billed that carrier specifically before but we do our office visits with our biopsies like that multiple times a day. Usually a personal or family history for the EM and then the neoplasm uncertain behavior for the bx with the modifier 25 with no problems. I would fight those ones as long as your documentation supports it.


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