Integrity MBC

Q: I had services performed that I was told are covered by my insurance. I’m now being told that insurance didn’t cover it and I’m being held responsible! Why was I told it was covered, and now being held responsible for a bill?

A: Coverage of benefits differ greatly from who the responsible party is for payment. As always, if the benefit goes toward your deductible, you’ll owe this and a co-insurance until/ if you are covered at 100%. If you’re being denied on a covered service, did your records prove the medical necessity behind coverage? This means- 1: Did the claim record (UB04/ HCFA) have the appropriate diagnosis pointers assigned? 2- Did records support the claim form and medical necessity.

Often, certain procedure codes are only covered under specific diagnosis codes. Each carrier has their own rules, so it’s imperative for the procedure to be coded and billed appropriately. This does not mean a Coder or Biller will add codes for payment. If the medical records reflect the payer rules, they’ll bill it out accordingly to ensure a claim is not denied. It’s important that whomever is handling billing stays current on payer rules to minimize denials and cut back patient frustrations.

If this is a common issue in your practice, feel free to reach out for assistance. We do consults as well!