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Billing Not Medically necessary Charges

  1. Default Billing Not Medically necessary Charges
    Medical Coding Books
    I have a question and was hoping someone could help. I work for an infertility clinic and we have a protocol for a procedure that no matter the medical necessity we still perform the procedure because we get better results. If we call and can not get auth for it, are we still obligated to bill it to the insurance for a denial? Also if they end up paying it after denying auth for it and we sent the medical records in for review, is it fraud to keep the payment? Infertility is a hard specialty to bill for because alot of insurances are not familiar with the procedures. I always thought that no matter what the outcome of payment is for a procedure, we still had to bill for it because we provided the service. Is there a modifier we could add to the procedure to show we might not meet the criteria for payment? Thanks.

  2. #2
    Default Billing for "Non-Covered Services"
    I also am a biller for a Fertility Practice. I have services that are non-covered. Obviously, we can't bill insurance for our entire package of InVitro or Insemination when they don't pay for Infertility Treatment. However, there are somethings that they consider non-covered, like for some insurances Semen Analysis or the HSG is "non-covered", which is ridiculous because insurances pay for diagnostics and treating underlying causes and these two are diagnostic. (On a side note, that's where we Fertility Clinic billers need to send letters to our State Insurance Commissioner and show them how insurance companies aren't abiding by their contractual agreements) However, I bill them and have had BCBS tell me you can't bill the patient but other insurances tell me it's at our discretion but they encourage us to take the contracted rate only. I will usually do that for the patient. Something like our OR fee...I have the patient sign a Non-Covered Services agreement so they understand up front that it is possible the insurance company won't pay the fee and they will be responsible for it. Then I only charge them what is costs us to have them in our OR... staff costs, meds, supplies etc.

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