# "we cannot tell you how to bill"



## ollielooya (Jul 12, 2011)

Colleagues,
I'm so tired of hearing this "canned script."  What can we expect to hear when calling the insurance companies and inquiring their claims processing preferences for bilateral billing?   Surely, they can provide information as to WHAT method is preferred, and if not---why not?  Is there anyway to get past this...should I ask for a supervisor?  Right now, we're having issues with Anthem as to whether they prefer one lines or two with the anatomical modifiers.  Basically we're told to try and see which way will work?  That is ridiculous!  I tried to take this to Provider Relation Support in the Escalated services but have yet to receive a response.  

So, is there a magic button to push or question to ask?

How do you veteran billers handle this?

Suzanne E. Byrum CPC


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## Lisa Bledsoe (Jul 12, 2011)

I would try to see if they have a written policy that you can access.  I know United HealthCare has one...I am quite certain that Anthem does as well.  It could be a lot like looking for a needle in a haystack though!


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## StephanieTheCoder (Jul 12, 2011)

When I was dealing with this same issue in Dental, all I could do was keep track of what I billed out, and watch for what they paid and what they turned down.  Friggin' Insurance companies with that line just won't clarify.  Even if you try for a manager.


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## tpontillo (Jul 13, 2011)

Sometimes you would have to find out who your provider representative is and have a meeting with them.  They should be able to tell you what their company prefers.


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## MMAYCOCK (Jul 14, 2011)

*Bilateral Billing*



ollielooya said:


> Colleagues,
> I'm so tired of hearing this "canned script."  What can we expect to hear when calling the insurance companies and inquiring their claims processing preferences for bilateral billing?   Surely, they can provide information as to WHAT method is preferred, and if not---why not?  Is there anyway to get past this...should I ask for a supervisor?  Right now, we're having issues with Anthem as to whether they prefer one lines or two with the anatomical modifiers.  Basically we're told to try and see which way will work?  That is ridiculous!  I tried to take this to Provider Relation Support in the Escalated services but have yet to receive a response.
> 
> So, is there a magic button to push or question to ask?
> ...


Most often they pay correctly when:

Billing one line with modifier 50 for professional claims:

2 lines with LT, RT for facility (ASC) claims. Most systems do not recognize modifier 50 in their facility payment platforms and need to see it billed on two lines in order to pay it at 150% of the allowable. It can then default to the multiple surgery rules that will allow correct payment. Billing on 1 line often results in an underpayment for facility claims.


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## jgf-CPC (Jul 15, 2011)

We always call our provider rep from the larger insurance companies in our office with any questions we need help with. If they can't answer it then they are obligated to find you an answer. I'm sure ours know us by first name basis now LOL!


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## btadlock1 (Jul 19, 2011)

ollielooya said:


> Colleagues,
> I'm so tired of hearing this "canned script."  What can we expect to hear when calling the insurance companies and inquiring their claims processing preferences for bilateral billing?   Surely, they can provide information as to WHAT method is preferred, and if not---why not?  Is there anyway to get past this...should I ask for a supervisor?  Right now, we're having issues with Anthem as to whether they prefer one lines or two with the anatomical modifiers.  Basically we're told to try and see which way will work?  That is ridiculous!  I tried to take this to Provider Relation Support in the Escalated services but have yet to receive a response.
> 
> So, is there a magic button to push or question to ask?
> ...



What are you usually trying to find out when you get this answer? Modifier? CPT codes that are payable? Diagnosis codes?

The problem isn't the questions you're asking; it's the _*way*_ you're asking them. You just have to find a different verbiage to ask essentially the same thing. First, avoid calling them altogether, if you can.
If you have a bundling denial, check your codes against the NCCI edit tables (here:http://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp). The *vast majority *of payer edit systems are based solely off of that. If you don't find your answer there, go to their website. Find the policies and protocol for coverage (also called 'medical policies', or something similar) - this may be easier said than done, so you might have to have customer service point you in the right direction. Find the guidelines that pertain to coverage for the procedure(s) in question. You'll be surprised to find that many payers (UHC, BCBS, Aetna) actually specify which codes are covered for which conditions and why, right down to the diagnosis. If you_ still _don't have any luck, then you're going to have to call. 
Ask questions in this order:
"I see that procedure code XXXXX denied on this DOS, and the EOB says [reason]. Could you please give me more information about that denial?" (Do *not* accept them just reading the EOB to you again. You can read; you need to know what it _means_.) 
"What code did this deny as [bundled/inclusive/global/mutually exclusive/incidental] to?"
"Is this an NCCI edit, company policy, or group-specific coverage guideline?" 
"Where can I find literature/written disclosure on the policy used in the denial?"
"Is the diagnosis we billed a covered indication for this service?" 
"Are you showing any problems with the modifier(s) submitted?"
"Could you perform a claim estimation to tell me how it would have processed if we had billed it [another way] instead?"

Keep drilling until you get the answer you're looking for - like a 5 year old. Just keep asking 'Why?'. You don't understand why it processed the way that it did.
Like this:
"The diagnosis submitted is invalid."
"Invalid, how? What does that mean?"
"It's not valid for the procedure code."
"I don't understand. Do you mean it's not covered for this procedure, or it's mismatched?"
"It's not covered for the procedure."
"Is this a company policy, or is it specific to this group?"
"It's a company policy."
"Where can I find the information on the coverage criteria?" or "Is this procedure covered for diagnosis XXX.XX? I'm just trying to understand why this didn't pay, so I can let the doctor know."

Sometimes, you have to ask the same question several different ways, but whatever you do, *stay on point*: you need them to explain their position to you until you* totally *understand it. They don't need to tell you _how to bill _- they only need to tell you *why the way you billed it was wrong*. They should be able to do it, because that's their job. If you run into someone who clearly can't explain it to you, ask for their supervisor. Playing dumb is extremely effective. I highly recommend it.  Good luck!


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## mitchellde (Jul 19, 2011)

Brandi is correct.  You need to stay away from asking specific billing questions on specific claims such as "which modifier should I use"  or "how should I bill this?"  these are things they are not allowed to answer.  But you can rephrase the question to ask about policy for a particular issue.  Such as "What is you policy for billing bilaleral items, do you want 2 lines or a single line charge".  In this way the person is telling you how to submit a specific claim they are addressing a payer policy which they are allowed to answer.


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## btadlock1 (Jul 19, 2011)

mitchellde said:


> Brandi is correct.  You need to stay away from asking specific billing questions on specific claims such as "which modifier should I use"  or "how should I bill this?"  these are things they are not allowed to answer.  But you can rephrase the question to ask about policy for a particular issue.  Such as "What is you policy for billing bilaleral items, do you want 2 lines or a single line charge".  In this way the person is telling you how to submit a specific claim they are addressing a payer policy which they are allowed to answer.



This may help:
http://www.anthem.com/wps/portal/ah...w_001855.htm&state=nv&label=Claims Submission
"Modifier 50 is used to indicate a bilateral procedure. Effective November 1, 2007, we will be following CMS guidelines when processing bilateral surgeries/procedures. When a procedure is not identified by its terminology as a bilateral procedure it is billed on one line with the surgical procedure code and modifier 50. Bilateral surgeries/procedures are considered one surgery. The allowable amount is calculated by multiplying 150% of the unit value times the conversion factor. If the code is reported as a bilateral procedure, and is reported with other procedure codes on the same day, then the bilateral adjustment will be applied before applying any multiple procedure rules. This update of bilateral surgeries/procedures billed with (modifier 50) may impact how the multiple surgery reduction is calculated. And, the relative value unit (RVU) on the bilateral procedure may increase now that it will be reimbursed as one procedure causing it to become the primary procedure. For more information about Modifier 50 processing please refer to Anthem Colorado and Nevada Reimbursement Policy RE. 013 Multiple and Bilateral surgery. The notification letter explaining the processing of Modifier 50 is also located on the provider website."

http://www.anthem.com/provider/noapplication/f1/s0/t0/pw_ad088062.pdf


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## ollielooya (Jul 19, 2011)

Thank you all for arming me and others with excellent advice.  Hopefully this thread will be utilized many times.  Extremely helpful, indeed!

Suzanne E. Byrum CPC
Everett WA


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