Wiki E/Ms Being Downcoded by Insurance Company

[gprelow]

Hello,

Is anyone experiencing downcoding of EM's by Horizon Blue? If so, can you share how you are handling this? We have audited these charges, sent records to the insurance company but have not gotten little feedback on what the problem is. They are downcoding Level 4s & 5s to Level 3s. We are using the '95 guidelines.

Thanks,
Gwen

 

[mitchellde]

It will depend on the diagnosis and how you justify the higher level for that diagnosis. While you CAN document a level 4 or 5 the questiown is was THAT level necessary for the reason the patient was there. Medicare has stated that medical necessity ( diagnosis) is the overarching criteria for the level of care.

 

[thomas7331]

If you have reviewed the coding and feel it is correct and are not receiving any good explanation back when you send in the records, I would recommend going to your provider representative. Payers cannot just down-code without reason and they should provide you with their guidelines for doing this.

 

[ollielooya]

You might want to look into the ERISA law

This could be an option, but if you are unfamiliar with this--- it will take some research. If the member's policy's are funded whether in whole or part by their employer, you have options from which to confront the carrier for these downcoding practices. And to be empowered by the ERISA statutes you'll definitely need to get the patient involved by having a "written authorization to represent the member" signed by the patient. It's worth learning and knowing, especially as a biller. It takes time and effort but well worth it. Research ERISA on the web as it is a powerful tool. Unfortunately, can't offer a quick fix here.