Oncology & Hematology Coding Alert

Question: Our oncologist spends a lot of time on confirmatory consultations that insurers request, which I report with modifier -32. No matter which insurance I bill, however, they only pay the allowed amount. Should I even bother with modifier -32 if it doesn't make a difference to my payment?

Alabama Subscriber

Answer: You should definitely append modifier -32 (Mandated services), but the modifier won't make a difference to your reimbursement.

Simply put, insurance companies are usually going to pay only their allowable amount. You can charge as much as you want to on the bill, but you can't actually make the insurance company pay more than the allowable.

What you can do, if your state laws and your payer contracts don't have any provisions to the contrary, is bill the insurance company for your fee, take the allowable from the insurer, and bill your patient for the difference.  

Of course, this may not be a good public-relations strategy, and it could cause your referrals to disappear quickly.

So why use modifier -32 at all? This modifier is informational and tells the payer that the consult was initiated at the insurer's request and is not a redundant claim that simply repeats what the initial consulting physician performed.