jhanmer83
Networker
I work for an OB/Gyn practice in Alabama. We had a patient that we saw for her entire pregnancy. She had 18 prenatal visits (high risk complications), delivery, and 2 postpartum visits. We noticed that all of her prenatal testing was being denied by Anthem. After further investigation, we found out that there was a clause in her policy that required an office visit to be billed with all prenatal testing and a 25 modifier applied. We discovered this in June. Her first prenatal visit with us was in January and Anthem has a 90 day filing limit. We went back and refiled all of her claims, unbundling the antepartum per that unique clause in her policy. The early visits all denied for timely filing, but they continued to deny her prenatal testing even though it was billed the way they said it had to be billed per that clause. We spent hours on the phone with Anthem reps and after multiple attempts at reprocessing and the prenatal testing continuing to deny, we went back to billing globally. We billed the full global delivery in July, 59400, and billed her for the prenatal testing per the way her insurance processed. December rolls around and a rep from Anthem called. I spent another 2 hours on the phone with her. The patient had contacted Anthem questioning why she was getting billed. The rep said we needed to go back and refile all of her claims per that clause and request a special review due to extenuating circumstances. I specifically stated, we're past the filing limit at this point, but she insisted that we refile all of the claims. So that's what we did. All of the claims came back denied for timely filing. What had been paid was recouped so we got no payments at all for her entire pregnancy. We appealed and requested a special review of which came back denied. The timely filing denials were upheld. Is there anything we can do? My employer wants to bill the patient as self-pay due to all of this, but don't they have to abide by what her insurance says since we accept her insurance and are contracted with them? Hers was and has been the only Anthem policy with this particular clause so there was no expectation that we would/should have known about it. It just seems wrong that we get no payment when the Anthem rep told us to refile all of her claims.