Re: Max Units Responses
Jim DeWees
Description
Collection
Title:
Re: Max Units Responses
Creator:
Jim DeWees
Date:
1/18/2008
Text:
I have another response that I feel is important to share here.
On several claims that we have submitted here in my office, we get the Explanation of Benefits, along with a check (hopefully), and it is difficult to see the Quantity of what they actually paid. We have to carefully go over every claim (especially Anthem, Blue Cross Blue Shield EOBs) and check what the allowed amount is and compare it to the paid dollar amount that they approved.
The best example is dealing with the Check Sockets. Most every insurance allows up to 2 test sockets, if necessary. When these are billed to the insurance, they will only have the procedure code listed on the EOB, and then the billed amount, and then the allowed amount, paid amount, etc. When we go over these statements, we find that over and over again, they are only paying for ONE of the test sockets and also ONE of the silicone liners. Even though they allow 2, when I have called and asked them over and over about this issue, they say to just re-submit it again, with a note. Well, then it just goes on and on, and they say it was processed correctly.
Finally I got to the bottom of this with ONE of the insurance companies that is guilty of this practice (Anthem). The person there said that for a few codes (like the test socket code and the liner code) they have no Quantity modifier allowed for that code. So, her recommendation was to just put it on two separate lines, and submit it that way, with the quantity of ONE per line. We did that one time, and it was rejected as a duplicate service, and not paid either.
So, now the solution that we have come up with is to bill the first test socket at the time of the fitting, with that date of service, and then bill the other test socket at the time of 2nd fitting (if that was performed). And for the liners, we bill one at the time of initial fitting, which is absolutely ethical and honest, and then bill the second liner at the time of delivery of the prosthesis, which is also ethical and honest.
The down side to all this is that it creates more billing time, making more transmissions and more claims to monitor. But, doing it this way has made it so that we are getting paid for the services renderred here, and not just giving away liners or anything else.
So, even though these insurance companies allow these quantities, it doesn't mean that they are actually paying for them. The big red flag that went off for me was what this insurance company paid for 2 liners, which was not even enough to cover the cost of ONE of the liners. It is a very low paying contract with an insurance company, but this was way below what could be even remotely acceptable. When I looked into it more, and saw that we did indeed bill for 2 liners, and they approved 2 liners, but didn't comment on the quantity that was PAID.
This is just something that I have wanted to share with everyone out there, to pay close attention to what these insurance companies are really paying, and some of their tactics to cut corners or increase their profits. I have seen the reports on a local CEO of a big health insurance company, and he got a $58 million BONUS check last year. The more they figure out on how NOT to pay for claims, the more bonus money they all get. What in the world would you do with that kind of a bonus check....and that is an annual event, not just a ONE time bonus. Maybe that explains why insurance premiums are going up 20-30% every year, or even more. And while the premiums go up, the rates or fee schedules for the providers never go up, and often times are going down every year. The difference is being made up by giving big bonuses out to the administrators of these companies.
This is just ONE of the many complaints and frustrations that we face here in my office dealing with insurance companies.
Take care, and have a great weekend everyone.
Jim DeWees, CP
_________________________________________________________________
Connect and share in new ways with Windows Live.
<URL Redacted>
On several claims that we have submitted here in my office, we get the Explanation of Benefits, along with a check (hopefully), and it is difficult to see the Quantity of what they actually paid. We have to carefully go over every claim (especially Anthem, Blue Cross Blue Shield EOBs) and check what the allowed amount is and compare it to the paid dollar amount that they approved.
The best example is dealing with the Check Sockets. Most every insurance allows up to 2 test sockets, if necessary. When these are billed to the insurance, they will only have the procedure code listed on the EOB, and then the billed amount, and then the allowed amount, paid amount, etc. When we go over these statements, we find that over and over again, they are only paying for ONE of the test sockets and also ONE of the silicone liners. Even though they allow 2, when I have called and asked them over and over about this issue, they say to just re-submit it again, with a note. Well, then it just goes on and on, and they say it was processed correctly.
Finally I got to the bottom of this with ONE of the insurance companies that is guilty of this practice (Anthem). The person there said that for a few codes (like the test socket code and the liner code) they have no Quantity modifier allowed for that code. So, her recommendation was to just put it on two separate lines, and submit it that way, with the quantity of ONE per line. We did that one time, and it was rejected as a duplicate service, and not paid either.
So, now the solution that we have come up with is to bill the first test socket at the time of the fitting, with that date of service, and then bill the other test socket at the time of 2nd fitting (if that was performed). And for the liners, we bill one at the time of initial fitting, which is absolutely ethical and honest, and then bill the second liner at the time of delivery of the prosthesis, which is also ethical and honest.
The down side to all this is that it creates more billing time, making more transmissions and more claims to monitor. But, doing it this way has made it so that we are getting paid for the services renderred here, and not just giving away liners or anything else.
So, even though these insurance companies allow these quantities, it doesn't mean that they are actually paying for them. The big red flag that went off for me was what this insurance company paid for 2 liners, which was not even enough to cover the cost of ONE of the liners. It is a very low paying contract with an insurance company, but this was way below what could be even remotely acceptable. When I looked into it more, and saw that we did indeed bill for 2 liners, and they approved 2 liners, but didn't comment on the quantity that was PAID.
This is just something that I have wanted to share with everyone out there, to pay close attention to what these insurance companies are really paying, and some of their tactics to cut corners or increase their profits. I have seen the reports on a local CEO of a big health insurance company, and he got a $58 million BONUS check last year. The more they figure out on how NOT to pay for claims, the more bonus money they all get. What in the world would you do with that kind of a bonus check....and that is an annual event, not just a ONE time bonus. Maybe that explains why insurance premiums are going up 20-30% every year, or even more. And while the premiums go up, the rates or fee schedules for the providers never go up, and often times are going down every year. The difference is being made up by giving big bonuses out to the administrators of these companies.
This is just ONE of the many complaints and frustrations that we face here in my office dealing with insurance companies.
Take care, and have a great weekend everyone.
Jim DeWees, CP
_________________________________________________________________
Connect and share in new ways with Windows Live.
<URL Redacted>
Citation
Jim DeWees, “Re: Max Units Responses,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/228918.
