codeseeker
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Seeking advocacy group for medical practices to combat baseless denials
Hi. I work for a billing group that services multiple medical practices. We are spending ridiculous amounts of time processing claim reconsiderations for denials that are baseless from any logical perspective. For example, one major commercial insurance company denied any payment for ligament repair performed at the same time as an arthrodesis/bone graft. Their rationale is that the ligament repair is "bundled" in the bone procedure. I tried to reason with the claims department, i.e., ligament repair is logistically and anatomically separate from the other procedures (we used modifier 59). Their response was, "we have no responsibility for the computer logic that bundled the 2 procedures"; in other words, "pass the buck". We get similar "run-arounds" in numerous other situations. Can someone please recommend a regulatory body (state or federal) or advocacy groups which could help organize other medical practices facing similar challenges with this insurance company, to combat these unethical practices either through legal action or on a legislative level? Also, does someone know of health care reimbursement consultants (either in academics or private) that specialize in these issues?
Hi. I work for a billing group that services multiple medical practices. We are spending ridiculous amounts of time processing claim reconsiderations for denials that are baseless from any logical perspective. For example, one major commercial insurance company denied any payment for ligament repair performed at the same time as an arthrodesis/bone graft. Their rationale is that the ligament repair is "bundled" in the bone procedure. I tried to reason with the claims department, i.e., ligament repair is logistically and anatomically separate from the other procedures (we used modifier 59). Their response was, "we have no responsibility for the computer logic that bundled the 2 procedures"; in other words, "pass the buck". We get similar "run-arounds" in numerous other situations. Can someone please recommend a regulatory body (state or federal) or advocacy groups which could help organize other medical practices facing similar challenges with this insurance company, to combat these unethical practices either through legal action or on a legislative level? Also, does someone know of health care reimbursement consultants (either in academics or private) that specialize in these issues?
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