Ever wonder why sometimes when you get reimbursed for a claim, the insurance company “changes the code to a more appropriate payment code”? You filed the claim as 99214 but got paid for a 99213 or worse, a 99212. This practice is called downcoding.
Do you have to accept it? Well, in some cases you do. Much will depend on the contract you have with the insurance company. Some contracts will only allow providers to bill certain cpt codes. In that case, they can change a billed code to one of the allowed codes. Or the contract may specify that you can only bill a certain number or percentage of claims in the higher codes.
But sometimes an insurance company will simply code your claim and it is not due to the contract specifications. In that case you can appeal. We recently had a claim that the insurance company deciphered a 99214 to a 99213 and told us that they only allow one provider to bill a 99214 every 6 weeks for a patient. That’s playful. How can that guideline be applied to any patient?
Sometimes we just have to remind the insurance companies that the doctors are the ones who determine the needs of the patient. In this case, we sent office notes and a letter advising them that we were appealing the processing of the claim. The doctor had met the requirements to justify the billing of a 99214 and his “guidelines” were not adequate. We receive the payment of the difference about 10 days later.
Therefore, if you have problems with your claims being decrypted and they are not due to the contract specifications, you should file an appeal. Don’t just accept what the insurance company does. That’s what they’re counting on. Just think of how much money they save on providers who do nothing about it.
Copyright 2008 – Michele Redmond
