Wiki BS charging MRI Copays for Echo's

aunderhill

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Is anyone else having issues with diagnostic testing copays with BS? We are getting $325.00 copays for echo's and nuclear studies. The patients benefits always show $85.00-$95.00 for diagnostic testing. Every time we call they say it is an MRI which they are obviously not. The reps will not budge. Appeals do not work. We test in office and bill as such. Has anyone else experienced this and what have you done. This is so unfair to the patients!
 
What CPT and/or revenue codes you are billing that are being charged the MRI copay rather than the echo or nuclear study copays?
 
Hello, we bill 93306 for echocardiograms and 78452 is the code getting $325.00 copay for nuc. These are in the office billed as POS 11. When I look up benefits online -professional lab/radiology/diagnostic testing it usually is $95 for copay. I can see MRI as a separate category as $325.00. Whenever I call I give them 93306 they tell me it is an MRI. What am I missing? Thanks.
 
Hello, we bill 93306 for echocardiograms and 78452 is the code getting $325.00 copay for nuc. These are in the office billed as POS 11. When I look up benefits online -professional lab/radiology/diagnostic testing it usually is $95 for copay. I can see MRI as a separate category as $325.00. Whenever I call I give them 93306 they tell me it is an MRI. What am I missing? Thanks.
You're not missing anything. 93306 and 78452 are most definitely not MRIs and anyone who's telling you otherwise doesn't know what they're talking about. Commercial plans generally don't hire coders as phone reps so it isn't surprising that they wouldn't know this - even so, they should know better than to be saying things like that. Have you tried escalating this to someone higher up? A supervisor or network representative.

In any case, insurance companies can decide to apply whatever copay these choose, and that's really between them and the members. It's good of you to advocate for your patients this way, but ultimately, it's up to them to be responsible for their portion of what is due. It's not popular when I say this, but I personally wouldn't use up too much of your physicians' time fighting this battle - if the patients feel that their benefit hasn't been paid correctly under their contracts, it's really up to them to pursue this with their insurer and it shouldn't fall on the provider. Providers' resources are already very much drained by the many administrative hurdles that payer's make them jump through without having to also be auditing whether or not payers are applying patient share correctly and trying to get them to correct their own mistakes.
 
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I agree with Thomas' response that you are not doing anything incorrect. I work for an insurance company, and at point I was a member appeals specialist, and since the financial liability lies with the member, it is up to the member to appeal the benefit applied to these services with their insurance company.

It is fantastic that you are trying to advocate on behalf of your patients, however it is up to the patient to resolve this with the insurance company themselves. The patient's appeals rights should be listed on their EOB, and it is important that they review their appeal rights and the process, as they will have a limited amount of time to appeal the benefit, usually 180 days from the date of the EOB for a commercial insurance plan. If they miss the deadline, they will likely have no recourse for getting the claim adjusted to apply the correct copay.

You as the provider can certainly provide any documentation the patient might need to submit with their appeal but ultimately for commercial insurance plans your hands are tied in this situation.
 
You're not missing anything. 93306 and 78452 are most definitely not MRIs and anyone who's telling you otherwise doesn't know what they're talking about. Commercial plans generally don't hire coders as phone reps so it isn't surprising that they wouldn't know this - even so, they should know better than to be saying things like that. Have you tried escalating this to someone higher up? A supervisor or network representative.

In any case, insurance companies can decide to apply whatever copay these choose, and that's really between them and the members. It's good of you to advocate for your patients this way, but ultimately, it's up to them to be responsible for their portion of what is due. It's not popular when I say this, but I personally wouldn't use up too much of your physicians' time fighting this battle - if the patients feel that their benefit hasn't been paid correctly under their contracts, it's really up to them to pursue this with their insurer and it shouldn't fall on the provider. Providers' resources are already very much drained by the many administrative hurdles that payer's make them jump through without having to also be auditing whether or not payers are applying patient share correctly and trying to get them to correct their own mistakes.
Thank you so much for this. It is very frustrating and wrong! I feel bad for our patients as they get the same answer as we do. I don't know how to get BS to look at this issue. I do want to bring this to a network representative, but I am not finding any information on how to find them. Do you have any tips to accomplish this? Thanks again.
 
I agree with Thomas' response that you are not doing anything incorrect. I work for an insurance company, and at point I was a member appeals specialist, and since the financial liability lies with the member, it is up to the member to appeal the benefit applied to these services with their insurance company.

It is fantastic that you are trying to advocate on behalf of your patients, however it is up to the patient to resolve this with the insurance company themselves. The patient's appeals rights should be listed on their EOB, and it is important that they review their appeal rights and the process, as they will have a limited amount of time to appeal the benefit, usually 180 days from the date of the EOB for a commercial insurance plan. If they miss the deadline, they will likely have no recourse for getting the claim adjusted to apply the correct copay.

You as the provider can certainly provide any documentation the patient might need to submit with their appeal but ultimately for commercial insurance plans your hands are tied in this situation.
Thank you so much for this. I am very frustrated with this situation. It is not fair and the patients are getting the same response we are. It seems like Bad Faith insurance!
 
@aunderhill I did a google search for Blue Shield of CA and found their guidelines and resources website https://www.blueshieldca.com/bsca/b...t_en/about_pc/contact_us/guidelines_resources and under the section titled "Provider Information and Enrollment - Blue Shield of California Network found the following contact info. You might give the phone number listed here a try to find a way to connect with your provider network relations representative.
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Thank you so much!
 
if you are going to pursue this yourself you need to get a clinical person on the phone or someone who can comment on the clinical aspect of their denial. you could also try a peer to peer review with your doc & one of their docs. i've worked on both sides of this issue & it is ultimately up to the pt to pursue this. you can spend days that you'll never get back with no results!!
 
if you are going to pursue this yourself you need to get a clinical person on the phone or someone who can comment on the clinical aspect of their denial. you could also try a peer to peer review with your doc & one of their docs. i've worked on both sides of this issue & it is ultimately up to the pt to pursue this. you can spend days that you'll never get back with no results!!
Thank you for this. I have now switched to guiding patients through the fight...as I did waste days. I just don't understand how an insurance can do this to their policy holders. Ultimately, I have let this go due to all the helpful information. Thanks again!
 
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