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Carrier audit for billing by time

  1. Default Carrier audit for billing by time
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    My employer has had an audit of charts and the insurance companies hired auditors have an issue with our billing by time documentation.

    Our providers always follow the CMS guidelines and then refer to the assessment and plan or other documentation in the note for the content of counseling. Its pretty obvious what the counseling is about due to treatment options, diagnosis or complications. We are a pediatric practice so parents and caregivers come in and require lots of time for answering questions. We spend a lot of time addressing what the parent/caregiver has seen on the internet too. This seems to be a common way to document the counseling topics. However the large carrier that audited us said that's not enough but would not give us an example of acceptable documentation for the content of counseling.

    My question is has any other practice had a billing by time recoupment from a carrier? If so were you given any examples of acceptable documentation beyond the CMS documentation guidelines?

    Thank you,

  2. #2
    Can I ask who this large insurance carrier is? I would consider appealing each claim if you are following CMS rules and guidelines to the letter .

    CMS E/M guidelines explain:

    "When counseling and/or coordination of care dominates (more than 50 percent of) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit time in the hospital, or NF), time is considered the key or controlling factor to qualify for a particular level of E/M services. If the level of service is reported based on counseling and/or coordination of care, you should document the total length of time of the encounter and the record should describe the counseling and/or activities to coordinate care.".

    While insurance carriers can implement their own policies, the above guideline seems to be the standard. Carriers tend to not give you examples (as they don't really want to pay you), but they should at least have a policy to show or at the very least be more specific. If you can tell me which carrier this is, I can look around for you and see if I can dig something up.
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  3. Default Carrier Audit for Billing by Time

    Wellmark BCBS of Iowa is the carrier that seems to be re-writing the CMS guidelines. I appealed every claim and did get them to back off of some of them. But their logic was not consistent. We did an in person meeting with the giants staff and medical director twice.

    Their staff doctor said that billing by time must still meet the "medical necessity" requirements for a level of service.

    SO if a patient was improved and no medication changes Wellmarks reply was there was no need for a counseling discussion. Our Physician refuted the Wellmark doctor many times saying parents and guardians have many questions and require long discussions and counseling about the patients diagnosis because the caregivers want to ask about alternate treatments. The caregivers are on the internet and come in with a list of questions. Even though the patient may be improved and no medication changes there are still other issues with patients like behavior since starting medication, discussions about tapering off treatment, repeat studies, psychiatric diagnoses being treated by a Psychiatrist and those medications etc. Even with a decrease in seizures or headaches there is still a long term plan that is counseled on at every visit.

    The Wellmark physician would not agree even though the Wellmark coding staff agreed with me. They are just so big they can do whatever they want and we have to recourse. That is why I am asking if any other practices have been bullied into submission and given on the fly guidelines to follow when billing by time.

    I wanted to report Wellmark to the Iowa insurance commissioner and even higher if necessary but my superiors asked me back off. UGH! If this were happening to other practices I feel like we could join together and have more power in numbers if we all report to the insurance commissioner.

    And guess what-since Wellmark got their way they have done another audit of the same group. It will not end they will keep going until we bill level 3 for follow up visits even though our specialists spent 30-50 minutes counseling families.
    Thank you.

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