Ah, nice trick, huh?
Depending on your responses to the previous posters' suggestions, perhaps go through the route of filing a complaint. Does the payer have the authority to change codes on the claim form, especially since your practice/physician is ultimately responsible for the accuracy of that material? The downcoding is by the payer's estimate, but it must defend that stance through appeal. Be sure you utilize 1997 and/or 1995 guidelines to support your claim. There is likely something the contract that relates to Tricare's use of both sets.
Finally, if the payer is altering your claim form contents (which is occurring through any downcoding), establish that is permitted in your contract. If the provider is solely responsible for the submitted claim, Tricare may be in violation of a number of regulations, contract provisions or laws. And, if the provider is "re-coding" the claim, that is likely a violation of conflict of interest clauses in your contract--though you'd need to have attorneys make that call.
Finally, ask for a higher level determination by Erica Russel, the supervisor of that division.
This might sound like a stretch, but I'd bet this practice is not permitted.
Last edited by kevbshields; 02-17-2012 at 06:49 PM.
Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I