The contract a patient signs with the insurance company holds true no matter what. Have you been in a situation where you wanted to contest a denial by an insurance company based on irrational payer guidelines? You may be right to think this is like trying to break down a stone wall, but you are not helpless to change to situation to your favor. Consider this gastroenterology situation: You want to fight an insurance company for payment for 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) with 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). In denying your initial claim, the insurance company states in writing the following guidelines: "Exceptions to Modifier 59: The following endoscopic biopsy procedures will not be allowed with the associated endoscopic therapeutic procedures: 45380 with 45383-45385. Decision: Rationale: What do you do then? Your steps in fighting for your claim could make or break your practice's chance for a fair reimbursement. Unfortunately, the insurance company can set any rules it wants and you are forced to play by them when your physicians sign the contracts. Still, you can break through the barriers by learning this 3-step tactic, says Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. Follow These Three Steps Step 1: The first thing you have 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 is set forth in the contract, use the contract in your appeal to fight this arbitrary policy and get it overturned. Step 2: Step 3: