Hysteroscopy 58558

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Hello all,

I am a bit behind with this but if you all can help I would really appreciate it. The in office medicare allowed amount is $1400.00 for this code.

I am not receiving payments reflective of this. Do I need to appeal? We do not see Medicare patients, only BCBS FL and AL, Aetna some others that have out of network benefits.

What am I doing wrong?

Thank you so much for your help!!
 

thomas7331

True Blue
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The first step would be to verify that you are billing the correct place of service. If you are performing these in the office, but are billing a facility place of service, then that could be causing a payment error.

The next step would be to look at your contracts. If your provider is contracted with BCBS and Aetna, then they should be paying you according to what is specified in that contract, and if they are not, then an appeal or a discussion with your network representative would be appropriate.

If, however, your provider is not contracted with the payers, there is not much you can do about the amount of your payment, but you do have a couple of options that can help. One is to precertify or preauthorize the service and try to get the insurance to agree to pay it at in-network benefits levels (if the service was provided on an emergency basis, or if there was no network provider available, payers will often agree to this). If not, then you may at least be able to negotiate a rate in advance with the payer. But failing this, if you know that the service is going to be paid as out of network, you should be making the patients aware that they will be responsible for any unpaid balance. You may be able to calculate the amount that will be due in advance if you review the patients' benefits, in which case you can require that they pay all or a portion of it before receiving the service.

Ultimately though, without a contract, there is little you can do to compel a payer to increase their reimbursement, but that does not mean you just have to accept whatever they pay. Hope this helps some.
 
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