Wiki Split Fragmented Billing

[suki_26]

Has anyone heard of this? As of 06/04/2023 Emblem health has implemented a new policy.

Split/Fragmented billing is defined as services rendered by the same provider on the same date of service and submitted on more than a single claim. Split billing is inappropriate billing

Is anyone else sending "multiple claims" due to necessity?
I can see if an office is sending 2 or 3 codes on one claim and then another claim for an additional code. But our office sends claims with 20 or more codes at a time. We are Out of network PCPs with our own lab in house. The claim for bloods alone is usually 18 codes and the office visit is usually another 5 - 15 codes. When I questioned the GHI supervisor he said well you will have to contact your clearinghouse to get all codes on the same claim... or you will have to submit your claims paper. I said so what about all the claims we have sent since June tha have been paid? he said they may ask to recoup them all. ????????? Im at a loss for words.

 

[andersona1229]

The only time we send multiple claims for the same date is if we ran some tests and so did a reference lab. One claim would be ours and the other one is the reference lab with -90 on it. We also have to "split" due to payer policy at times; some payers won't accept presumptive and definitive urine drug testing on the same claim and require it to be submitted separately.

I think that is the kind of split billing they're referring to, not if you have to use multiple 1500s because of how many codes are being billed. In that case, those multiple 1500s with the same internal claim # on them count as one claim.

 

[suki_26]

The only time we send multiple claims for the same date is if we ran some tests and so did a reference lab. One claim would be ours and the other one is the reference lab with -90 on it. We also have to "split" due to payer policy at times; some payers won't accept presumptive and definitive urine drug testing on the same claim and require it to be submitted separately.

I think that is the kind of split billing they're referring to, not if you have to use multiple 1500s because of how many codes are being billed. In that case, those multiple 1500s with the same internal claim # on them count as one claim.

I agree. Our software wont allow us to send it all on 1 claim but this supervisor swears that is not allowed. I can't even see how that could be a thing. I guess in this age of technology Emblem health wants to go backwards instead of forward. No clue.

 

[amyjph]

Think about it this way, if the claim has more lines than will fit on one page, it may require multiple pages, but that is all still the same claim. It's page 1, 2, 3 of one claim. It would be if a totally separate claim with a new and different claim number was billed completely separately. I think this is what it means. Like @andersona1229 mentioned above, it's two different things, this is not where you have multiple pages of the same HCFA with the same claim number.

Like, if I was billing a huge spine surgery, for example, I might have three pages each with 6 line items, but when it goes out it is still all "one claim".