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Wiki Insurance changing a provider's claim

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amadams

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Does anyone have any documentation that prohibits an insurance company from changing a provider's claim? For example, if a modifier is required for payment, should the insurance company add the modifier, or deny and send back to to provider for correction? I'm under the impression that insurance companies should make NO changes to a provider's claim without the provider's instructions to do so.
 
I work for an insurance company and we are not allowed to make additions or corrections to a bill that has been submitted. That would require making assumptions about what the provider meant to bill, and we all know what making assumptions leads to. If there is an obvious error on the claim form we either process the bill as-is with the missing/incorrect info, or we call the provider to ask if they consider what they sent to be correct. We can then make adjuments to the bill per that discussion as long as we document who we talked to and that the changes were made per their request.
 
I have seen insurance companies add modifiers, normally 51, for multiple procedures, but not change the code. You might want to dig a little deeper in the provider manual or ask to talk to a supervisor with the insurance company. Sorry! You see all kinds of things:confused:

Josie J, CPC, CPC-H
 
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