I'm conducting an audit of a TPA and am claiming that there is double billing when a hospital bills a radiology procedure without a modifier (global) and an unrelated physician bills the professional component, there is double payment for the professional component. The TPA is claiming that whenever a hospital bills a code such as radiology, it is "understood" that it is for the technical component only, even though there is no modifier. According to the TPA, if another provider, not an employee, then bills for the professional component, my claim that the professional component is double billed is incorrect because only the technical component was paid to the hospital.
Are different rules applied if the patient is inpatient vs outpatient? For instance does the DRG payment include only the technical component?
Has anyone heard of this "understood" rule that hospitals bill for the technical component only even without a modifier?
Does anyone know of a policy/rule addressing this that would be considered to be a billing standard that can be cited in court? My searches have turned up nothing that would be considered as an authority.
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