Pediatric Coding Alert

Question: Do I have to bill Medicaid and commercial patients the same way?

Pennsylvania Subscriber

 
Answer: This is a gray area, and the answer depends on your own compliance department. If you are affiliated with a university or a multispecialty group with Medicare patients, you probably have a policy that requires you to bill all claims following CMS (formerly HCFA) rules. In general, in the absence of specific guidelines from the payer, compliance departments require billers to rely on CMS guidelines.
 
If a commercial payer will pay for something that CMS won't, however, compliance departments don't object to your billing accordingly -- if you have something in writing from the payer indicating approval for filing the claim.
 
Some consultants recommend sending a certified registered letter to the medical director, saying you intend to bill a certain way and that if there is a problem with this you expect to hear back from the payer within a certain time. If you don't hear back, you can continue to bill as before.
 
Many compliance departments don't like the above method, however. They would rather have a positive statement from the payer indicating exactly how a procedure should be billed. You can send a fax to the payer with simple "yes" and "no" responses to be circled.
 
Tip: The best time to contact a payer is when your contract is up for renewal. You have the most leverage then, and may be more likely to get a favorable response.