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Rebundling

  1. #11
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    Quote Originally Posted by kevbshields View Post
    To my knowledge it is usually "allowable" practice to rebundle based upon contract language. Because they are the payer, they have not only a right to review documentation, make assessments on the accuracy of a submitted claim, but also to render payment in accordance with those findings.

    One can only hope that the reviewers are at least as knowledgeable as the coder who coded the claim. Hence, the importance of having the CPC-P!
    I agree with you completely... unfortunately commercial carriers don't usually require their first line of processors to be credentialed.... that's why it is always key for us to question their decisions when they use this practice. I have seen where a corrected claim with a modifier changed the coding edits they get when processing... so I would always review when the insurance company takes it upon themselves to "re-code" your claim for you. Usually they do this without requesting medical records and the coder may have access to information they didn't have when making the decision to change the codes.

    And WOW... look at all of your credentials...You are one busy guy... I don't know when you have time to code... just a question... does test taking get easier as you go along... I'm truly impressed.
    Barbara Haskins CPC

  2. #12
    Location
    Madison Area Chapter in Madison WI
    Posts
    113
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    I gotta jump back in here. I can't speak for all carriers, but most carriers retain the submitted codes, but listing the code in which they base their reimbursement on the EOB. It is a "standard" reimbursement function on many commercial editting products. I may be splitting hairs on what they are actually doing, but as a payer/provider consultant, I wanted to share my perspective.
    Happy Coding, Claudia


    Claudia Yoakum-Watson, CPC
    Coding, Compliance, & Reimbursement Solutions
    [email]ccrsconsulting@tds.net
    ccrsconsulting.com - website

  3. #13
    Location
    North Carolina
    Posts
    3,126
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    Claudia,

    Do you work for a payer? I'm intrigued by your statement "but as a payer/provider consultant". Providing both services, in my opinion, can be a conflict of interest. How do you provide a non-bias opinion? I've been in this business for many years and I have, yet, not found a middle ground between the provider and the "payer". I do not mean for this comment to sound disrespectful...only inquisitive.

  4. #14
    Location
    Madison Area Chapter in Madison WI
    Posts
    113
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    Rebecca, I appreciate your question. I'm not sure how to respond because I love what I do and when I start talking about it, I can get a little long winded. If anyone is interested in specific details, just send me a private message. I don't want to bore others if they aren't interested.

    Fortuately for me and my clients, we work hand in hand to understand the similarities and differences in provider and payers. We all are pretty familiar with the differences, but you'd be suprised how similar they are.

    My main focus is correct coding and reimbursement regardless if it's a payer or provider. I present sessions on payer/provider relationships. Most of it is understanding the other's perspective and talking the same language when it comes to coding issues. Very few payers have coders on staff so they are happy to have someone explain coding compliance. You'd probably be surprised at what happens when payers and provider speak the same language and stop butting heads. I know it sounds like I'm wearing rose colored glasses, but I see this regularly. Don't get me wrong, there is still a lot of politics in both areas. But I enjoy making it just a little easier.

    OK, enough from me. I hope this sheds some light on one of things I do as a payer/provider consultants do.
    Happy Coding, Claudia


    Claudia Yoakum-Watson, CPC
    Coding, Compliance, & Reimbursement Solutions
    [email]ccrsconsulting@tds.net
    ccrsconsulting.com - website

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