Colleagues,
I'm so tired of hearing this "canned script." What can we expect to hear when calling the insurance companies and inquiring their claims processing preferences for bilateral billing? Surely, they can provide information as to WHAT method is preferred, and if not---why not? Is there anyway to get past this...should I ask for a supervisor? Right now, we're having issues with Anthem as to whether they prefer one lines or two with the anatomical modifiers. Basically we're told to try and see which way will work? That is ridiculous! I tried to take this to Provider Relation Support in the Escalated services but have yet to receive a response.
So, is there a magic button to push or question to ask?
How do you veteran billers handle this?
Suzanne E. Byrum CPC
What are you usually trying to find out when you get this answer? Modifier? CPT codes that are payable? Diagnosis codes?
The problem isn't the questions you're asking; it's the
way you're asking them. You just have to find a different verbiage to ask essentially the same thing. First, avoid calling them altogether, if you can.
If you have a bundling denial, check your codes against the NCCI edit tables (here:
http://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp). The
vast majority of payer edit systems are based solely off of that. If you don't find your answer there, go to their website. Find the policies and protocol for coverage (also called 'medical policies', or something similar) - this may be easier said than done, so you might have to have customer service point you in the right direction. Find the guidelines that pertain to coverage for the procedure(s) in question. You'll be surprised to find that many payers (UHC, BCBS, Aetna) actually specify which codes are covered for which conditions and why, right down to the diagnosis. If you
still don't have any luck, then you're going to have to call.
Ask questions in this order:
"I see that procedure code XXXXX denied on this DOS, and the EOB says [reason]. Could you please give me more information about that denial?" (Do
not accept them just reading the EOB to you again. You can read; you need to know what it
means.)
"What code did this deny as [bundled/inclusive/global/mutually exclusive/incidental] to?"
"Is this an NCCI edit, company policy, or group-specific coverage guideline?"
"Where can I find literature/written disclosure on the policy used in the denial?"
"Is the diagnosis we billed a covered indication for this service?"
"Are you showing any problems with the modifier(s) submitted?"
"Could you perform a claim estimation to tell me how it would have processed if we had billed it [another way] instead?"
Keep drilling until you get the answer you're looking for - like a 5 year old. Just keep asking 'Why?'. You don't understand why it processed the way that it did.
Like this:
"The diagnosis submitted is invalid."
"Invalid, how? What does that mean?"
"It's not valid for the procedure code."
"I don't understand. Do you mean it's not covered for this procedure, or it's mismatched?"
"It's not covered for the procedure."
"Is this a company policy, or is it specific to this group?"
"It's a company policy."
"Where can I find the information on the coverage criteria?" or "Is this procedure covered for diagnosis XXX.XX? I'm just trying to understand why this didn't pay, so I can let the doctor know."
Sometimes, you have to ask the same question several different ways, but whatever you do,
stay on point: you need them to explain their position to you until you
totally understand it. They don't need to tell you
how to bill - they only need to tell you
why the way you billed it was wrong. They should be able to do it, because that's their job. If you run into someone who clearly can't explain it to you, ask for their supervisor. Playing dumb is extremely effective. I highly recommend it.
Good luck!
