Each day, our billing experts encounter hundreds of claim denials, rejections, and underpayments. At WCH Service Bureau, our account representatives identify and reprocess every claim that has not been paid appropriately. Most underpayments are completely random and are caused by nothing but mistakes done by insurance carriers and healthcare providers. However, it would be silly for us to assume that there are no patterns leading to six-figure revenue losses. For 21 years, we have witnessed insurances violating the law and deliberately not paying for some services. Recently, our account representatives have resolved a major underpayment case, helping our client to get back it their well-deserved $12,000 from a major New York insurance carrier.
Are you sure that your practice is fully immune to systematic revenue losses?
From the very first days of WCH Service Bureau, helping healthcare providers has been our ultimate goal. From a small private practice to major facilities, over 500 practitioners have entrusted their insurance claims billing to us. Today, we would like to share our recent accomplishments. This February, we have helped our client to resolve a major series of denials worth over ten thousand dollars.
One of our clients is an osteopathic doctor and a primary care physician. Currently, they run a small outpatient practice in Brooklyn, NY. Each day, dozens of patients insured under Medicare, Medicaid, and commercial policies visit this doctor’s office to get rid of their back pain and improve their overall lifestyle.
Our client has submitted hundreds of claims for osteopathic manipulative treatment services (OMT, CPT 98926-98929) to FidelisCare. According to the CMS clinical policy, OMT cannot be furnished and reported without an applicable office visit procedure (CPT 99202-99215). Separate office visit procedure codes must be reported with the modifier 25 to indicate that OMT is not incidental to a consultation. Insurance carriers are obliged to pay for both services since this modifier indicates that they have been performed separately. However, sometimes payers enact internal payment policies that create obstacles in the processing of such claims. FidelisCare, for example, does not pay for office visit procedures reported together with OMT unless the medical records are provided. Nowhere does the payer indicate this rule. It is not specified in any official reimbursement policy of FidelisCare, let alone the CMS. Osteopathic providers will not find this rule on the FidelisCare website or their enrollment contract. Moreover, FidelisCare does not notify healthcare providers about a true denial reason for the service on the Explanation of Benefits (EOB), instead simply saying that an office visit is bundling to an OMT procedure. This cannot be true, since the primary purpose of modifier 25 is to indicate that procedures are not incidental to each other. Interestingly, in the case of our client, FidelisCare has never requested any medical records for these services from our client. As a result, all of the affected claims had been underpaid, causing a major decline in the practice reimbursement. We have been struggling to find out the true denial reason of the affected procedure codes. Following the advice of the FidelisCare network representative, we gathered and submitted the medical records for each affected claim in the form of a collective appeal. The payer has swiftly upheld its original decision, stating that the records were submitted too late. All this forced us to submit an appeal to the New York State Department of Financial Services.
Shortly afterward, WCH Service Bureau has won this appeal on behalf of our client, and all the affected claims have been reprocessed and paid in full. An entire outstanding amount of $12,000 illegally withheld from our client, has been paid in full. The client is satisfied, and so are we.
And this is just a single story of accomplishment!
In our upcoming edition of WCH Insights, we will be sharing some tips & insights on how to tackle such cases quickly and efficiently.