WCH Wins a Case Regarding Modifiers; Client Gets Full Payment

3/14/2020

WCH Wins a Case Regarding Modifiers;
Client Gets Full Payment


Last March 1, 2019, FidelisCare of New York updated its system without notifying providers. As a result, a lot of Mental Health providers noticed drastic changes in payments. To be specific, payments were reduced.

WCH immediately contacted a FidelisCare Behavioral Health area representative upon noticing this change. We were told that all Psychiatric Nurse Practitioners should bill for services with the SA modifier “Nurse practitioner rendering service in collaboration with a physician for supervised NP services.” It was surprising since facilities were required to use the modifier, and the affected healthcare providers were part of a PC. Moreover, there were no published changes in FidelisCare policies that would guide Psychiatric Nurse Practitioners to use the above modifier on their professional claims.

However, the area representative told WCH that the only way to get paid correctly according to the fee schedule is to use the SA modifier to identify a specialty, regardless of the fact professional claims contain rendering provider name and NPI by which the specialty of a contracted provider can be easily identified. We also brought to the attention that there were no updated policies where FidelisCare requires or guides Psychiatric Nurse Practitioners to use the modifier SA on their professional claims.

Reprocessing affected claims

After a few months of communication, WCH opened a huge project with the FidelisCare Behavioral Health area representative to reprocess the affected claims, as FidelisCare was requesting us to do so. FidelisCare notified us that some of the affected claims were too late, and there was no guarantee it would be paid.

Adhering to the new SA modifier

While waiting for the claims processing, WCH started submitting new claims accordingly with the SA modifier. FidelisCare was paying those at an accurate rate. However, the project was still pending.

Inconsistencies with the Modifiers

After a few months, a new FidelisCare Behavioral Health area representative was assigned to our project. While the project was pending, another reduction appeared for Psychiatrists. We steadfastly contacted our new FidelisCare Behavioral Health area representative. We were informed that we must use modifiers AF ”Specialty Physician Provided Service” for all MD and DO providers. More than that, all other providers such as social workers, and even psychologists must use modifier AG “Primary Physician Provided Service/Physicians other than Psychiatrists.”
We mentioned to the area rep that no one notified us of such requirements. Additionally, the regulations that the previous area rep provided us contained just general information on how to use the Ambulatory Patient Groups (APG) Payment Modifiers by facilities and hospitals. We mentioned again that our provider type is different and asked to confirm the rules must be applied.

Communicating with FidelisCare

We had no choice but to ask our FidelisCare Behavioral Health area representative to come to our office and discuss the case. At our meeting, the area representative instructed us to use all those modifiers just to identify the provider’s type. The reason is that Fidelis uses the APG model for that, regardless of the facility, hospital, or group practice.

We discussed the definition of the modifiers and scope of its use. We likewise brought to their attention that there were no underpayments for social workers, psychologists, and those specialties not considered to be “physicians.” The representative reiterated that we must use for them the AG modifier. Otherwise, payment will be reduced, and all old claims recouped. After that meeting, another project was opened for MD and DO providers with AF modifiers.

Prodding FidelisCare for further explanation

Considering claims for social workers and psychologists, we still had some doubts. We also had some additional discussions with the FidelisCare Behavioral Health area representative. Still, the area rep insisted on using AG modifiers.

After that, all claims were corrected. Unfortunately, all corrected claims for social workers and psychologists came back with a reduced payment, and all new claims were underpaid. We contacted the FidelisCare Behavioral Health area representative again, but the rep didn’t want to explain anything and ignored our calls.
After several months of discussions, meetings, research, projects opening, and corrections, we decided to remove the AG modifier, regardless of what was instructed by the area representative.

The FidelisCare Behavioral Health area representative visited our client’s office and informed them to use the modifiers. Otherwise, the payment will be reduced. The representative also told our client that it seems like we are removing AG modifiers in the FidelisCare system.

Receiving correct payments from FidelisCare
The client was incredibly upset, but we took responsibility as professionals and made the client believe in us. As a result, we’ve got all the money back— and we got even more as we started to submit claims without the AG modifier. FidelisCare was processing claims with a correct rate. The FidelisCare Behavioral Health area representative had no comments on this matter.

The corrected claims for Nurse Practitioner with SA modifiers, even those where timely filing limits were exhausted for processing, were all paid. Corrected claims for MDs and DOs with AF modifiers are being paid as well, and some are still in process as part of a project.

The case showed that area representatives at insurance carriers are not always right. Because of this, we convinced the client to sign a new group contract with FidelisCare to make all claims process smoothly with no problems.

We work hard to ensure our clients receive accurate and fair reimbursement for the services they render. 
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