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.

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.

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.

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.

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.

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.