Wiki Help bundling denial

[detesler]

we are noticing that Oxford is paying for J3301 but denying the administration codes stating its mutually inclusive.
We have never had a problem in the past but even after multiple appeals stating CPT and HCPCS are billable separately and admin of the medication is separate from the actual medication they only way they wind up paying is if we omit J3301 and submit only 11900 or 11901.
Please be so kind advise on what are recourse is.

 

[thomas7331]

This is pretty clearly an error on the part of Oxford. Drug HCPCS codes never include a procedural or professional component. Someone has incorrectly programmed their claims system. Are you sure they're making the administration inclusive to the drug charge and not to some other code that was submitted?

As to your recourse, you just need to keep working up the chain of command. I always recommend going to a network representative if you are unsuccessful in dealing with the claims or appeals departments. The final recourse if nothing else works is to renegotiate or terminate your contract with the payer. It's a good idea to track and keep a record of all of the issues and denials that are costing your practice money and quantify this over time. When it comes time to renew the contract, you can show this data to the contracting representative so they know exactly how much money they are costing you, and this information will help to negotiate better rates for your provider. Quantifying your denials is also as helpful a tool to evaluate whether or not the costs of doing business with a particular payer outweigh the benefits that your practice is getting from being in the network.

 

[detesler]

This is pretty clearly an error on the part of Oxford. Drug HCPCS codes never include a procedural or professional component. Someone has incorrectly programmed their claims system. Are you sure they're making the administration inclusive to the drug charge and not to some other code that was submitted?

As to your recourse, you just need to keep working up the chain of command. I always recommend going to a network representative if you are unsuccessful in dealing with the claims or appeals departments. The final recourse if nothing else works is to renegotiate or terminate your contract with the payer. It's a good idea to track and keep a record of all of the issues and denials that are costing your practice money and quantify this over time. When it comes time to renew the contract, you can show this data to the contracting representative so they know exactly how much money they are costing you, and this information will help to negotiate better rates for your provider. Quantifying your denials is also as helpful a tool to evaluate whether or not the costs of doing business with a particular payer outweigh the benefits that your practice is getting from being in the network.

Thank you so much for your response. My appeals dictate the AMA guidelines on HCPCS drug codes. Would you have the link so I can attach the exact literature to my appeals?