Insurance Policies

pchamp25

Networker
Messages
32
Location
New Durham, NH
Best answers
0
Hi All!
I am having trouble with my billing dept and HPHC. We are getting denials on modifier 59 when attached to a second colonoscopy or EGD CPT code. Example, we bill 45385 & 45380 59 and HPHC denies 45380 as being inclusive. I found the HPHC payment policy explaining these will be denied but my billing manager is fighting to get these paid. If I am correct, if an insurance policy has a specific rule, that rule is final. It does not matter how many times we appeal, there will always be a denial. Correct?
 
Most likely you are correct - if your provider is contracted with the payer, there is usually a clause in the contract stating that your provider agrees to accept the payer's policies. I would recommend reviewing your provider's contract to verify if that is the case, and also reading the payer's policy carefully to see if there are any provision that allow for exceptions or appeals in particular cases and if there are, that will guide you on when or whether you can make a case for having a denial overturned.
 
If you're contracted with the payer, then your contract would typically have a clause that includes acceptance of the provider payment policies.

Is this the document that you found? https://www.harvardpilgrim.org/prov...sites/7/2020/07/H-2-Gastroenterology-PM-1.pdf

If so, then that document clearly states that they reimburse only one procedure:

"The endoscopy code with the higher allowable when multiple endoscopy procedures are performed using the same or multiple techniques, at the same or different sites, in the same anatomical area (for example: when the removal of colon lesions by ablation and snare technique are performed at the same session, only the code with the higher allowable (removal of colon lesions by ablation) will be reimbursed)."

IMO, your billing manager is wasting their time trying to pursue this - their time would be better spent pursuing claims that would actually have a chance of getting paid.
 
Top