# Insurance saying Dr. billing incorrectly



## tpontillo (Dec 6, 2011)

I would like to know what and how other office's have handled this situation.  I have been getting calls from patients stating that their insurance company has told them that the doctors office billed the claim incorrectly and that is why something was applied to their deductible instead of being paid.  I have had numerous patients calling and stating that their insurance is telling them this.  I pull note to verify the coding and we billed properly.  I work in GI and alot of this has to do with the colons.  Insurance tells patient that if it was billed as a screening then it would be paid at 100% so patient calls us and wants it changed.  I have gotten into arguments with the patients and also with the insurance companies regarding this.  I would like to know how other offices have handled this.  Is there a form that they have explaining this?


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## penguins11 (Dec 6, 2011)

We have had this same issue come up with consults.  One of our commerical carriers still accepts consults.  The patient's coverage does not cover consults, only office visits so the carriers are telling the patient's it was billed incorrectly.  I called our provider service rep and pointed out to our provider service rep that without a copy of our office note, the csr talking to the patient can have no idea about our documentation and what is correct and incorrect billing.  Our provider service rep sent out a mass memo to the csr's and we havent really had a problem.  I also politely tell patients that what is medically necesary and what is billable may not be covered by their insurance depending on their coverage.


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## ajs (Dec 6, 2011)

tpontillo said:


> I would like to know what and how other office's have handled this situation.  I have been getting calls from patients stating that their insurance company has told them that the doctors office billed the claim incorrectly and that is why something was applied to their deductible instead of being paid.  I have had numerous patients calling and stating that their insurance is telling them this.  I pull note to verify the coding and we billed properly.  I work in GI and alot of this has to do with the colons.  Insurance tells patient that if it was billed as a screening then it would be paid at 100% so patient calls us and wants it changed.  I have gotten into arguments with the patients and also with the insurance companies regarding this.  I would like to know how other offices have handled this.  Is there a form that they have explaining this?



This is an ongoing problem in most physician offices.  Unfortunately the customer service reps who answer the phone just want to make their client happy.  The client is not happy with the insurance company for not paying a claim, so the rep diverts the attention to the physician office by telling them we "billed it wrong".  So the patient calls us and says the insurance rep said to "just change the codes".

My usual response was to state that I cannot change codes as we are required to bill based on the documentation in the patient chart of the encounter.  For us to send claims to the insurer that do not accurately reflect what happened during the encounter would be considered "fraud".  I will be happy to resubmit the claim with a copy of the chart notes, and ask the insurance company to review the claim based on the notes provided, but the codes will not be changed as long as they accurately reflected what was in the notes.

Insurance has become complicated for lots of people, I just looked at it as an opportunity to provide some education to our patients on how their plan works, so next time they will be aware.


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## tpontillo (Dec 6, 2011)

Thanks.  I have contacted the provider rep but that hasnt worked.  I have tried explaining to the patients about it being fraud to change the codes just to get a claim paid but they dont seem to understand that.  Just thought someone had a better way of handling this.  Thanks for the responses.


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## jgf-CPC (Dec 6, 2011)

You also need the correct guidelines for colonoscopies since my physicians office did code it incorrectly and I was charged the deductible which was incorrect. I appealed it myself and won. Please know when to bill it as a screening and which codes to use with it.


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## tpontillo (Dec 6, 2011)

I do have the guidelines.  I do double check these when a patient calls.  They are being billed correctly.  The only insurance I have a problem with is Cigna.  They apply it all to patients deductible when it should be paid at 100%.  I do call Cigna on these and have them reprocess the claim


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## agaluski (Dec 6, 2011)

I run into the same issue at the office I work for. I work for a small cardiology office. I have dealt with insurances doing this for years. They tell our patients we billed incorrectly for patients in observation status, to bill preventative codes for EKGs, to bill well care visits. Unfortunately, once the patient has already found someone to blame, it is nearly impossible to go backwards. In terms of EKGs I explain to the patient in full detail why they came to our office and why that led to an EKG being done. I explain to the patient that while I understand their frustrations, the truth of the matter is that we are a specialist and they would not have come to our office if they were not having a "cardiac issue", therefore, calling an EKG a "preventative service" would simply be a lie. I have even had patients call the office disputing bills for copays because they felt as though they were not "sick" when they came to see us, and felt we should have billed a well care visit. Obviously there is more to the situation than that but after spending hours re-evaluating claims that were billed correctly the first time around and looking up each individual insurances policy regarding preventative services there is simply no easy answer. I have heard it all and I find little assistance from any of our provider representatives. In fact, the majority of the time I try to contact any provider representative, it takes multiple messages before I even receive a call back. The whole situation is very difficult to deal with, I completely sympathize with where you are coming from.


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## mdoyle53 (Dec 7, 2011)

I have run into this exact problem professionally and personally for colonoscopies.

It seems that the CPT code is usually correct but the ICD-9 could be the issue.  If a patient comes in for a screening, it should be coded a screening and then also the code for the polyp, etc.  It is usually the screening code that is missing that causes it to go to a deductible.  

That being said, it is usually a fight with the insurance carrier as they are looking out for their best interest and that is to blame someone else.


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## lorig (Dec 7, 2011)

mdoyle53 said:


> I have run into this exact problem professionally and personally for colonoscopies.
> 
> It seems that the CPT code is usually correct but the ICD-9 could be the issue.  If a patient comes in for a screening, it should be coded a screening and then also the code for the polyp, etc.  It is usually the screening code that is missing that causes it to go to a deductible.
> 
> That being said, it is usually a fight with the insurance carrier as they are looking out for their best interest and that is to blame someone else.



On a personal note, my insurance company has told me that if I go in for a screening colonoscopy it is covered at 100%; however, if a polyp is found during the colonoscopy the entire charge will go to my deductible.  Obviously, a patient would have no idea beforehand if their screening colonoscopy will be paid at 100% or go to their deductible and become their responsibility.  I think this is very unfair for insurance companies to claim that this is covered under their plan as part of their wellness coverage without telling the patient the whole story.


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## lorig (Dec 7, 2011)

mdoyle53 said:


> I have run into this exact problem professionally and personally for colonoscopies.
> 
> It seems that the CPT code is usually correct but the ICD-9 could be the issue.  If a patient comes in for a screening, it should be coded a screening and then also the code for the polyp, etc.  It is usually the screening code that is missing that causes it to go to a deductible.
> 
> That being said, it is usually a fight with the insurance carrier as they are looking out for their best interest and that is to blame someone else.



On a personal note, my insurance company has told me that if I go in for a screening colonoscopy it is covered at 100%; however, if a polyp is found during the colonoscopy the entire charge will go to my deductible.  Obviously, a patient would have no idea beforehand if their screening colonoscopy will be paid at 100% or go to their deductible and become their responsibility.  I think this is very unfair for insurance companies to claim that this is covered under their plan as part of their wellness coverage without telling the patient the whole story.  We have a responsibility to make patients aware of this ahead of time.  My doctor's office did not tell me this, but luckily, being in the medical field, I knew enough to call the insurance company ahead of time.


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## weshelman (Dec 7, 2011)

I have been on both sides of this issue. When I worked for a major insurance company we were told emphatically that we were not to dispute the provider's coding when patients called. And definitely not to offer our opinion on what the coding should be. 

Now I am in a plastic surgery practice and get calls from patients wanting us to change our diagnosis code on cosmetic surgery so their insurance will cover it. It's a never-ending problem.


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## tpontillo (Dec 7, 2011)

I have also had issues with some insurance companies where I would bill a screening colon for example as 45380-33 with V76.51, 211.3.  The insurance will see that there was a polyp even when the 211.3 is second and process it as diagnostic.


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