WCH Service Bureau WCH Service Bureau
  • Services Services
    • Medical Billing
    • Provider Credentialing
    • Medical Auditing
    • Real-Time Eligibility
    • MIPS Support
    • Webinars
    • Practice Analysis
  • Products Products
    • Credentialing Application ©
    • iSmart EHR ©
    • PMBOS ©
    • Time Management Program
  • WCH Franchise
  • Company
    • About
    • Our Offices
    • Careers
  • News
    • WCH Insights
    • Healthcare News
    • WCH News
  • Contact Us
  1. Home
  2. > WchNews
  3. > WCHNewsItem
Phone: 888-924-3973 Technical support Pay Now iSmart Login

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. 
Liked the article? Share with friends:

WCH News

January 18, 2023
WCH Accomplishments 2022
AT THE BEGINNING OF THE NEW YEAR, IT IS CUSTOMARY TO  SUMMARIZE THE RESULTS OF THE PREVIOUS ONE. WE THANK YOU FOR YOUR TRUST AND SHARE OUR ACCOMPLISHMENTS WITH YOU.Creden...
December 26, 2022
Professionalism is Not Afraid of Obstacles
Professionalism is Not Afraid of Obstacles WCH is always happy to share its success stories with you. This month, we want to feature a recent story about the journey of our pharmacy specialty cus...
November 07, 2022
NEVER STOP LEARNING
“Education is the most powerful weapon which you can use to change the world”, Nelson Mandela. We are glad that people who gathered at the WCH team share this opinion and are proud that th...
August 09, 2022
Introducing WCH CredyApp
Introducing WCH CredyAppWCH Credentialing team knows all challenges of handling credentialing internally. WCH has done credentialing for over 20 years, helping healthcare providers of various specialt...

Healthcare News

January 18, 2023
Get $26,000 per Employee with Federal ERC Credits
Get $26,000 per Employee with Federal ERC CreditsLike the PPP/EIDL, there is no repayment as it is a tax credit of up to 26,000 per W-2 worker you employed in 2019/2020.It is no secret that the Corona...
December 26, 2022
Cuts in Physician Payments Will Reduce Access to Care
Cuts in Physician Payments Will Reduce Access to Care The MGMA’s data shows that 90% of medical facilities reported likely declines in access to care following the 2023 payment cuts in the ...
November 29, 2022
LockBit Ransomware Campaign: New Suspect
Lockbit ransomware campaign, the variant that has been known to target healthcare in the past, is back on the radar. Thus, the Department of Justice reported that on November 15, 2022, the alleged cha...
November 04, 2022
Warning about the threat of imprisonment for breaking the HIPPA Law
If prosecutors find that providers disregarded PIR (protected information rules) in a way that warrants more punishment than fines and penalties - the doctor faces up to a year in prison on charges of...

Ready to start?

Contact Us
linkedin
⟶ let's start
WCH Service Bureau
Payment options
WCH Service Bureau WCH Service Bureau WCH Service Bureau WCH Service Bureau WCH Service Bureau
Pay Now
Services
  • Medical Billing
  • Provider Credentialing
  • Medical Auditing
  • Real-Time Eligibility
  • MIPS Support
  • Webinars
Products
  • Credentialing Software ©
  • iSmart EHR ©
  • PMBOS ©
  • Time Management Program
Company
  • About
  • Contact Us
  • Careers
News
  • WCH Insights
  • Healthcare News
  • WCH News
Support
  • Feedback
  • Technical Support
  • Privacy Policy
888-924-3973
3047 Avenue U, Brooklyn New York 11229
Fax: 347-371-9968
Follow us:
2023 WCH Service Bureau, Inc.® | Web Design and Programming by WCH Service Bureau, Inc.® | Privacy Notice
Can I help you?
Anna
Anna
Administrative Assistant
Hi, what service does your question relate to?
Medical Billing
Provider Credentialing
Medical Audit
Franchising
PMBOS
iSmartEHR
Eligibility
MIPS Service
Other
What are you interested in?
Let me help you.
Please, leave your contact details and we will answer your question.
Thank you for your request, we will respond as soon as possible.
Let us Help You

Dear Provider,
WCH can help your practice in your credentialing needs! Using a credentialing specialist with the knowledge, expertise and connections that can help position your practice ahead of time. Let us help you today! During credentialing process WCH becomes your external credentialing department for all communications, submissions, follow up and any other questions that will come up during the process.

WCH Specializes in:

  • All individual Medical specialties
  • Mobile IDTF
  • Single & Multispecialty Groups
  • Urgent Care, Labs, DME, Pharmacy
  • Article 28, 32, 31
  • Revalidation, Reinstatement &
  • Exclusion
We help Providers in All States! WCH provides Clarity, Comfort and Security in your Practice.
Let us Help You
Wch SErvice Bureau

Medical billing services offered by WCH Service Bureau go far beyond the usual understanding of billing.

 

What we offer is not just excellent professional billing and collection services. We also stand as guardians of your reimbursement and compliance with federal, state laws and regulations as well as private insurance policies and procedures.

 

Do it right! Do it with WCH!

Let us Help You
Wch SErvice Bureau

Periodic medical chart auditing is vital for any healthcare provider and medical practice. Let the professionals evaluate your coding, billing, and documentation practices! Our auditors are AAPC-qualified CPMAs (Certified Professional Auditors) and CPCs (Certified Professional Coders). We perform comprehensive Chart Auditing. We can do the following services for you:

  • Identify areas of risk leading to upcoding or downcoding and medical coding accuracy;
  • Ensure that coding practices are compliant with the regulations set forth by private and government payers;
  • Evaluate Incident to guidelines and services performed on collaborative premises;
  • Perform Analysis of Denials/Duplicate billing /Appeal process/Modifier usage;
  • Review Front Desk work including but not limited to: Eligibility verification/Benefit maximums verification/Excluded services verification/Authorization process/Patient responsibility (deductibles, copays, coinsurance)/Coordination of benefits;
  • Evaluate Insurance plans participation and consistency of contracted rates;

Do it right! Do it with WCH!

Try WCH PMBOS
Request information
Perfect! Please fill in the form

What service does your question relate to?

Let us Help You
Wch SErvice Bureau

Do it right! Do it with WCH!

REQUEST FREE DEMO
Planned number of Providers : *
Specialty : *
Job Role : *
Perfect! Please fill in the form
Perfect! Please fill in the form
Have any questions? Please contact us practiceanalysis@wchsb.com
Leave us a feedback
 
Thank you
for your feedback!
Wch SErvice Bureau

Thank you for your interest in our company!
Our team will process your request and will respond as soon as possible during regular working hours.

Subcribe
Subcribe Subcribe
 
Our site uses cookie.

This site uses cookies for analytics, personalization and advertising. By continuing to browse it, you agree that we use of cookies. To find out more or change your cookie settings click here.