Wiki Changing Code For Reimbursement

[freyday53]

90837-psychotherapy-60 minutes
UHC will not pay this code without prior auth; obtained by provider=unrealistic expectation. Spoke with Appeals Department and were instructed to submit 90837, receive denial, submit a CORRECTED CLAIM using 90834 (psychotherapy-45 minutes). They will not provide this answer/advice in writing. Downcode for reimbursement? Wouldn't that be viewed as fraudulant since documentation does not match? Your thoughts are appreciated as we educate our Administration.

 

[Pam Warren]

In your case, I would not resubmit a 'corrected claim'. You didn't make a mistake in billing...the auth was simply not obtained. Correct coding as well as the terms of your contracts with payers indicate that you are expected to code the service that was provided. Re-coding, down/up coding, switching diagnoses, etc., solely to receive reimbursement is fraud, plain and simple. And I don't use that F-word very often, because there are a lot of murky areas. This is not one of them. There's a reason you aren't getting that in writing from UHC--because you were given bad advice, and someone in customer service felt sorry for you.

I worked in mental health for 8 years....all psychotherapists were expected to obtain or have proof of preauthorization before they saw a client and were expected to also participate in case management for further authorizations if they were going to continue to treat the patient. That's an expectation for psychotherapy clinical practice, and a requirement based on your contract with the payer. The therapists I worked with (several dozen) all knew that this was part of doing business. I recommend that your Admnistration reveiw their contracts, and identify what they've agreed that they will do, because whether or not it's an 'unrealistic expectation', as a participating provider, they've already agreed to abide by the UHC guidelines, and the pentalty for not doing so is that your therapists are not going to get paid. Your providers also run the risk of being dropped from the panel of preferred providers if they continue to ignore the expectations that they've already agreed to.

Good luck.