When a carrier, including those I am contracted with, denies my claim stating the procedures are inclusive, I look at my CCI edits and if they are not in the CCI edits, I fight the carrier.

I have two they like to deny... IV & E&M and EKG Interp & E&M. I wrote to the AMA regarding these two and I received a letter stating they were not inclusive. I use this letters when I fight the carrier.

If the inclusive codes are surgical with E&M, I show them that the patient had multiple injuries in addtion to the wound that required the repair. This normally works because at first, you;re dealing with a computer program, like Claimcheck, that was programmed by the carrier to deny these codes. When you send the appeal with the chart and CPT pages, the appeals person approves the appeal and you get paid.

With the case of the Blues, I met their claims reviewer. She used to be a nurse and she has no clinical training or certification as a coder, yet, she makes the decisions for the carrier regarding whether the procedures are inclusive or medically necessary. I sent her a copy of the CCI edits, the pages from the CPT and the letter from the AMA showing her these codes were not inclusive and she states "In my opinion, these codes are considered inclusive because they are always done in the ED." I even received a letter from their Medical Director saying the same. Again, it was in their opinon these codes were inclusive. I asked for documentation to support their opinion and they refused.

I recently wrote to the AMA complaining. They called me and understood but, the AMA will not take a stand when it comes to BIG Insurance companies. Here, the insurance company violates their copyright to the procedure and the AMA does nothing and will do nothing. I received another letter stating these codes are not inclusive and I am back to fighting the carrier.

I tell the carrier, as long as it is documented in the chart, the CCI edits show the procedres are separate, and the CPT manual shows they are separate I demand payment. If they deny, or refuse to respond t y appeal within a specified timeframe, then I take their denial or refusal to respond to mean they do not accept financial liability for the procedure and I will then be allowed to bill their patient, regardless if the patient is an HMO patient or not.

I have billed the patient and the carrier calls and orders me to stop billing. I tell them no. After all, what will they do? Terminate my contract where they will have to pay the full charges of my claims? They can't offset my payment because it's against Florida Law to do so without my written consent. Do they yell breach of contract? Heck they breach my contract with all of the unpaid claims and incorrectly paid claims!!! You complain and what do they do?? Nothing. So that's what I do when they complain.

My letter to them follows the letter of my State Statute regarding balance billing an HMO patient. They refuse to accept financial responsibility and that allows me to bill the patient. If they want to take me to court, I have all the documentation to prove my side, I'm sure a judge will want to see their documentation. Guess what.. they will lose.

If a patient already paid, do not refund the patient because when the procedures are separate you are due payment. My recommendation is to fight and fight and fight. My second recommendation is to take your fight to the President/CEO of the carrier. Always go to the top. The moment you win, you set a precedence for future claims denials. After all, David fought Goliath and won!

Steve V.
Florida _________________________________________________________________

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