I'm wondering if anyone can give me a general idea on how an insurance company decides which E/M level to pay? For example, we bill level 4 (99284), but we are paid for level 3. We use ACEP guidelines, but this insurance company uses their own guidelines and uses their own interpretation. Do you suppose they are only looking at the charges? that's the way it seems, because how would they know if a medication is administered and monitored without looking at the medical record? the flowsheet would show vitals, the nursing notes would state more detail about the patient being monitored, etc. So, I'm just trying to get a better understanding of why it seems we are being "under"paid for services.
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Wiki E/M FACILITY BILLING AND REIMBURSEMENT FOR EMERGENCY DEPARTMENT
- Thread starter bag4498
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thomas7331
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Paying a different level than what was billed could be due to different reasons. As you've said, a payer would need to review the medical records in order to be able to determine whether or not the level billed was supported by documentation, so that could be one reason - if they have requested records or if you had submitted them with the claim, they may have determined that the level was incorrectly billed and paid based on their review, which is something that you should be able to appeal if you disagree.
However, some payers have also developed policies and/or benefit language where they will reduce a level based on the diagnosis billed on the claim, without a record review. These policies are based on the assumption that certain conditions are not serious enough to warrant higher than a certain level of care. If your provider is contracted with these payers, the contract most likely has language that states that by participating, your provider has agreed to follow these policies. If that's the case, you may wish to review your payer policies and get more information about their guidelines for this. There may also be an appeals process for this that you can follow if you disagree with the level assigned under the policy.
In the absence of either a review or records or a published policy, though, I would say that changing the level billed by any provider would be inappropriate and I would certainly recommend challenging any payer who did this to either give you their rationale for it in writing or otherwise correct the payment to that which your provider has submitted and should be entitled to be paid.
However, some payers have also developed policies and/or benefit language where they will reduce a level based on the diagnosis billed on the claim, without a record review. These policies are based on the assumption that certain conditions are not serious enough to warrant higher than a certain level of care. If your provider is contracted with these payers, the contract most likely has language that states that by participating, your provider has agreed to follow these policies. If that's the case, you may wish to review your payer policies and get more information about their guidelines for this. There may also be an appeals process for this that you can follow if you disagree with the level assigned under the policy.
In the absence of either a review or records or a published policy, though, I would say that changing the level billed by any provider would be inappropriate and I would certainly recommend challenging any payer who did this to either give you their rationale for it in writing or otherwise correct the payment to that which your provider has submitted and should be entitled to be paid.
Thank you so much for this information. I will see what our contract with them states.
Thomas is correct that some contracts will stipulate what levels will be reimbursed. You may be able to appeal individual cases, again depending on carrier policy.
I will also note that I have had a carrier state we billed "too many" high level services, and then implemented the practice that all our claims billed level 4 or 5 were paid level 3, and we had to appeal every one to get the accurate reimbursement. It was not in our contract as such, but the contract was worded that permitted this. As expected, I was very displeased with this process. I tried unsuccessfully to get the carrier to reconsider, but since it's a small carrier, didn't pursue very aggressively.
I will also note that I have had a carrier state we billed "too many" high level services, and then implemented the practice that all our claims billed level 4 or 5 were paid level 3, and we had to appeal every one to get the accurate reimbursement. It was not in our contract as such, but the contract was worded that permitted this. As expected, I was very displeased with this process. I tried unsuccessfully to get the carrier to reconsider, but since it's a small carrier, didn't pursue very aggressively.
So here's my argument, this carrier is basically looking at the charges and basing what level they plan to pay off of that. How is that possible when there aren't certain codes to charge for? example....level 5 criteria includes "extended social worker intervention". you will not find a CPT code for that to put on the bill. So, without looking at the patients chart, they automatically downgrade the level. Also, what gets to me is that there are not certain definitions as to what they consider "extended". they can interpret it anyway they like. Also, they will choose the level 4 administration and monitoring based on certain J codes. so if a certain drug is given, lets say for pain and the pain is monitored during the stay, but that J code for pain medication isn't on the "list", it automatically downgrades to a level 3. Again, without looking at the chart and seeing all the vitals taken, nursing notes, etc. how can they make that determination?? our E/M coders are going off of ACEP guidelines and this carrier has made their own outlined criteria guideline and it seems a bit stricter than the ACEP one. We have over 1000 patients with this carrier just last year alone that were downgraded. I want to include things in our appeals letter that will help our case. Any advice?
thomas7331
Guest
I'm a little confused with what you're saying here as you're saying this is done by E/M coders but you're citing services such as social workers, drugs and infusions which would contribute to a facility level, not an E/M level. Are you coding facility or professional?
But either way, if you're planning to confront the payer, you're going to have start with the policies and contracts first. You can't make a strong case without first knowing what you're up against. If your provider has agreed to accept a policy, then you have to know what the policy says in order to even begin to know whether or not the downgraded payments are in line with your contract with that payer. You might want to consider setting up a meeting with one of your payer's network representatives to talk this through and get additional information before trying to prepare a case.
But either way, if you're planning to confront the payer, you're going to have start with the policies and contracts first. You can't make a strong case without first knowing what you're up against. If your provider has agreed to accept a policy, then you have to know what the policy says in order to even begin to know whether or not the downgraded payments are in line with your contract with that payer. You might want to consider setting up a meeting with one of your payer's network representatives to talk this through and get additional information before trying to prepare a case.
sorry for any confusion. I'm not coding anything, I'm auditing charts from this particular payer. I'm attaching a snippet of the charges, which apparently what this carrier is basing the level they paid us. When I look at the CPT codes for hospital charges, I see the E/M CPT code that was chosen (I'm assuming the E/M coder puts this in). For this particular patient, you will see we billed a Level 5, however this carrier only paid us a Level 3. You will see medications charged, but apparently those particular J codes didn't match the ones on their list to make them pay us at a level 4. However, when I was reviewing the chart and trying to determine why they only paid us a level 3, I came across nursing notes, flowsheets, etc that I could include in the appeal process that argues in fact, that the medications given were monitored. I was told the E/M coder uses the ACEP guidelines, however this particular payer has their own guidelines (which I found out is in the policy we signed). So when I'm auditing charts, I'm using this payers guidelines, but in doing so I'm also looking through the entire chart and basing it off of that, not just the charge list. As you can see there is a significant difference in what ACEP says and this payer says. The problem is there is no straightforward answer from this payer of what "monitoring means" or what "extended" means. Also wanted to include the difference in Levels, for our facility a Level 4 would be preparation of 2 diagnostic tests, the payers guidelines says it has to be 4 diagnostic tests.
Attachments
thomas7331
Guest
OK, so it looks like we're talking about a facility claim, so we're talking about the facility level, not E&M levels here. So facility levels are not based on documentation but rather on the costs and usage of facility resources - as far as I know, it is not an industry standard or coding requirement that facilities or payers must follow ACEP on this. Typically, every facility will develop their own internal guidelines as to how to arrive at these levels, but if your facility is using ACEP and the payer is using a different set of guidelines, then of course there are going to be differences, but you're taking the right approach by auditing based on the payer's own guidelines. It won't help you to argue a level is supported based on ACEP guidelines if the payer contract says that the level and payment will be determined by the payer's own policy.
Without reading those guidelines and the specific language, it's hard to guide you on this, but basically you'll want to identify cases where the payer is not following their own rules. If their policy is written in such a way as to state that the level will be determined by what other services are billed on the claim, then it won't help much to look at documentation or nurse's notes. But if the policy says that levels can be determined based on the content of the medical record and the documentation as to what actually took place during the encounter, and they are just making assumptions based on what they are seeing on the claim, then you have a better case. If so, I think what I would do in your situation is to find some good examples where the level they paid is clearly contrary to their own policy, and present these to your payer.
But you may want to look carefully at the language of the contract. Some contracts could be written in such a way as to allow the payers to make you 'guilty until proven innocent' - in other words, the payer is allowed to just look at your claim and make a judgment that your level is wrong, and then it is up to you to prove otherwise and you will be stuck just appealing these on a case by case basis.
Ultimately you want to show them that the claims pricing practices are conflicting with their own policy, are in violation of your contract, are costing your provider money in underpayments, and creating an administrative burden to correct. Payers these days fortunately are becoming a little more sensitive to the impacts their policies are having on providers, especially facilities, and they should be willing to work with you on this.
Without reading those guidelines and the specific language, it's hard to guide you on this, but basically you'll want to identify cases where the payer is not following their own rules. If their policy is written in such a way as to state that the level will be determined by what other services are billed on the claim, then it won't help much to look at documentation or nurse's notes. But if the policy says that levels can be determined based on the content of the medical record and the documentation as to what actually took place during the encounter, and they are just making assumptions based on what they are seeing on the claim, then you have a better case. If so, I think what I would do in your situation is to find some good examples where the level they paid is clearly contrary to their own policy, and present these to your payer.
But you may want to look carefully at the language of the contract. Some contracts could be written in such a way as to allow the payers to make you 'guilty until proven innocent' - in other words, the payer is allowed to just look at your claim and make a judgment that your level is wrong, and then it is up to you to prove otherwise and you will be stuck just appealing these on a case by case basis.
Ultimately you want to show them that the claims pricing practices are conflicting with their own policy, are in violation of your contract, are costing your provider money in underpayments, and creating an administrative burden to correct. Payers these days fortunately are becoming a little more sensitive to the impacts their policies are having on providers, especially facilities, and they should be willing to work with you on this.
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it’s hard in many situations to show them that they are not following their own policy since it states they have the final interpretation.
thomas7331
Guest
Yes, I imagine it would be! But even if there's no way around it for the particular claims you're looking at, it can still be a worthwhile effort - this can be something that is taken into consideration next time the contract is up for renegotiation. If the policy or language can't be removed from the contract, then it could be used as a bargaining chip to negotiate for higher reimbursement to offset some of the losses your facility might be experiencing from the level downgrades.