Do Away With Irrational Denials Through This 3-step Strategy

By Author: erinarticle
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No matter what, the contract a patient signs with the insurance company certainly holds true.


Have you ever been in a situation where you wanted to contest a denial by an insurance company based on irrational payer guidelines? You may be right in thinking this is like trying to break down a stone wall, however you're not helpless to change the situation in your favor.


Here's a gastroenterology coding situation:


You want to fight an insurance company for payment for 45380 with 45385. In denying your initial claim, the insurance company states the following guidelines in writing:


“Exceptions to modifier 59: The following endoscopic biopsy procedures won't be allowed with the associated endoscopic therapeutic procedures: 45380 with 45383-45385.


Decision: The endoscopic biopsies with endoscopic therapeutic procedures in the same anatomical area will follow standard coding logic, and no added payments will be made for these codes even when billed with modifier 59.


Rationale: The endoscopic ...
... biopsy is a key part of the therapeutic endoscopic procedure. When billed with a therapeutic endoscopic procedure in the same anatomical area, Generic ClaimCheck denies the endoscopic biopsy procedure.


What do you do considering this?


Your steps in fighting for your claim could make or mar your practice's chance for a fair reimbursement. But then the insurance company can set any rule it wants and you're forced to play by them when your doctors sign the contracts. Even then you can break through the barriers by learning this three-step tactic.


Here are three steps you can follow:


First, get a copy of your contract and see what degree of latitude your payer can take in comparison to AMA and CMS coding rules. If the insurer is violating what's set forth in the contract, use the contract in your appeal to fight this arbitrary policy and get it overturned.
If the contract's silent on this or allows such arbitrary use of rules in favor of the payer, you should gear up to ‘drop the payer as one of your participating payers. Don't develop cold feet; be ready to drop them in this stage.
Call for a meeting between your physicians and the medical director. Ask the medical director to justify this policy in clinical terms as to why the insurer doesn't pay a doctor for the diagnostic colonoscopy and the removal of polyps when you use modifier 59 (distinct procedural service) to point to different sites. Make clear that breaking the colonoscopy and the biopsy into multiple sessions will make the payer incur multiple facility fees, multiple anesthesia sessions along with the doctor professional fees.


For more on this and for other specialty-specific articles to assist your gastroenterology coding, sign up for a good medical coding resource like Coding Institute.