How to Negotiate in Advance for High-risk Ob Patient
Published on Tue Feb 01, 2000
To improve chances of receiving appropriate reimbursement when treating a high-risk ob-gyn patient, contact the specific payer as soon as possible. Explain the special conditions and the additional services that may be required to provide proper care to the patient.
We recently received a letter from a perinatology practice at St. Johns Mercy Medical Center in St. Louis. Chris Gazall, office coordinator for the practice, writes that the office consistently has problems getting reimbursed for high-risk obstetrics (ob) care. All the patients we see are high risk, Gazall writes. Most of them have diabetes, hypertension, preterm labor, twins, triplets, etc.
Gazall explains that they have been turning in their claims with full op notes, and billing for global care with a -22 modifier (unusual procedural service) and diagnostic code V23.89 (other high risk pregnancy). Still, writes Gazall, We never get paid anything but regular ob rates. Regardless of how much documentation the practice submits they are only being reimbursed for regular ob care. We then have to appeal every delivery, writes Gazall, and most of the time we lose the first appeal. If the doctor writes a letter to the insurer, it takes months to get a response, and that response is usually not in our favor. Understandably, Gazall feels that the practice should be getting paid for these difficult cases.
She also asks if the practice should be billing the office visits that pertain to the high risk separately (such as 99212-99215, E/M visits for established patients), exclusive of antepartum care, then billing for delivery and postpartum care.
We asked Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., for her input into Gazalls plight. For starters, she says that Gazall cannot bill office visits separately from the antepartum visits included in the global package until the office visits exceed the normal number of visitstypically 12 or so. Once this number of visits is reached, Gazall can bill for the additional office visits using the E/M codes.
Planning Ahead Avoids Problems
According to Callaway-Stradley and other coding experts we asked, the crux of the problem is that the practice is not negotiating in advance with their insurers. Particularly for high risk ob, says Callaway-Stradley, you want your carriers to know in advance what kind of problems you may encounter, and determine with them what they are willing to pay for. This leaves room for fewer surprises and denied claims in the end.
Curt Udell, CPAR, CPC, president of Emphysys Inc., a physician reimbursement and consulting firm based in Cumming, Ga., says that while there are always potential problems with reimbursement for any high risk service, there are steps to take [...]
