Insurance Q & A


Why do payers recoup money from previously paid claims out of future payments, and how can I stop them?

If the refund request is legitimate, there is really no recourse unless the claim is older than 24 months, in which case they can not legally take the money back in New York State. A biller should always call the carrier first to see which patient/claim they are taking the money for and why. There are many reasons why carriers will do this; patient did not have active coverage, multiple procedure reductions were not taken, another carrier was primary for the patient and should have been billed first, etc. These are all legitimate reasons to take money back. If there was an issue with coverage, then the patient is ultimately responsible for any lost revenue. If a carrier takes money back according to some internal methodology, such as claiming the usual and customary rate was too high, then they should provide you with the data they used to determine the allowed amount before taking money back. That type of an issue is very difficult to resolve and would require an experienced biller who knew the right questions to ask.


What do I do if a payer denies payment for a covered service?

There are many reasons why a covered service could be denied. The key to fixing these issues is finding out the exact language of the denial and addressing it accordingly. Some services are only covered when billed with certain diagnosis codes, other covered services are only payable if they are billed as a preventative service. Some claims deny because they need additional information from the patient, such as COB (coordination of benefits) or accident details (usually requested anytime there is an 800 or 900 Dx code used). In this case the patient needs to be contacted until he/she is compliant. Carriers also reserve the right to request medical records at any time before paying a claim, and if the notes are not typed or meet the definition of the service as described in CPT, the service can be denied. When these things happen a corrected claim or detailed medical notes should be submitted with the correct coding/information, and the claim will be paid. A claim can also be denied for timely filing, in which case, unless you have proof of timely filing via a clearinghouse report or certified return receipt, there is nothing you can do.


What do I do if a payer denies payment for a preauthorized service?

If a service is pre-authorized and the patient has effective coverage, a good biller should call the carrier and have the claim reprocessed. If the services were pre-authorized but the patient's coverage was not active or somehow terminated, it doesn't matter if the service is medically necessary because the patient did not have insurance at the time, or has a new insurance carrier that should be billed instead. This sometimes happens because the companies/departments that do the prior auth are separate from the insurance carriers and may not have access to patient's benefits. There can be many other reasons for this type of denial, like any of the ones mentioned in the topic above. Even services that have prior approval are subject to all the same issues of a regular claim; Dx mismatch, COB or accident details, etc. Prior approval just means it was determined to be medically necessary.


Can I stop a payer from “bundling codes?”

A good biller should know which CPT codes are mutually exclusive for that specialty and bill accordingly. Many bundled codes require a modifier (24,25,59,58,79,51) in order to be paid without denying out as inclusive. If a modifier is missed, a corrected claim should be submitted with the correct coding. If two codes are correctly bundled, the carrier is supposed to pay the one with the higher RVUs, and if it is not, then a biller should call to have the claim reprocessed. There are many resources, both online and in publication, that list which codes are mutually inclusive to each other. When you have this information, you can also strategically pick codes that have higher RVUs and also accurately reflect the services rendered. This should be done to optimize each claim for maximum return.


Can a payer determine how much I charge for an out-of-network service?

An insurance company can not determine what a patient is liable for when seeing a non-par provider. However, there are two areas where there can be a potential problem: 1) Patients should be made aware that they are responsible for the entire billed amount, not just what the insurance deems allowable for a given service. For example, if you charge $10,000 for a septoplasty, but the patient's plan only considers $8,000 an allowable charge, and then applies deductible and co-insurance to that $8,000, the patient must understand that non-par providers are allowed to balance bill them both the deductible and co-insurance applied to the $8,000 allowed amount and the $2,000 difference between the billed amount and the allowed amount. The EOB sent to the patient may only classify the deductible and co-insurance processed off of the allowed amount as "patient's responsibility," but the patient is still liable for the entire amount. A non-par provider can legally charge whatever he/she wants. 2) The allowed amount for any given plan is typically determined either by the fair market rate or a percentage of the medicare fee schedule. Despite this, out-of-network claims are still subject to third party pricing companies (Multiplan, MARS, Stratose, etc.) This is usually an attempt to lower reimbursement to the doctor for services rendered, but may also work in your favor to increase reimbursement for medicare repriced claims. If a provider agrees to a negotiated settlement through one of these companies, he/she also agrees not to balance bill the patient for anything above the agreed rate. In this case, you can not balance bill the patient for difference of the billed amount and the allowed amount.


How do I stop excessive requests for review of records, either before or after payment is made?

Insurance carriers will typically only do this if a provider fits a certain profile, ie high charges, high volume, high reimbursement, overuse of modifiers, overuse of high complexity E&M codes, etc. It could be a one time audit of a batch of claims or a permanent flag on the providers tax ID. In these cases the medical notes must be a perfect. In the case of a permanent flag on your tax ID, this would require a very experienced biller/manager who could develop a positive relationship with the auditor, rather than an aggressive, and costly, lawyer.