AAPC - Back to school
Results 1 to 2 of 2

Thread: Billing Not Medically necessary Charges

  1. #1

    Default Billing Not Medically necessary Charges

    AAPC: Back to School
    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.

Similar Threads

  1. SNF billing/charges
    By nprayer2 in forum Billing/Reimbursement
    Replies: 4
    Last Post: 12-18-2015, 07:43 AM
  2. Replies: 0
    Last Post: 08-15-2014, 12:53 PM
  3. Billing audiology charges
    By njbrown in forum ENT/Otolaryngology
    Replies: 5
    Last Post: 06-19-2013, 10:09 AM
  4. Replies: 0
    Last Post: 12-14-2010, 09:09 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.