It’s an all too familiar scene; you treat a high-level care patient in the ER, code the account and bill the claim to the payer, but the payment falls short of your normal allowable. Before, it was easy to tell when a payor was disputing the level of care codes for a claim; but more and more carriers are now automatically down coding higher level of service emergency medical billing claims with no notice.
Generally, when inquired on, these payers excuse the down coding of high- level service codes based off the primary diagnosis code. This differs from the customary guidelines for disputing a level of service code, which would normally be the payer requesting medical records and having a healthcare professional review the documentation to make the determination that the claim was coded incorrectly. When billing for emergency care physicians, the records are an essential part of deciding whether a claim was coded incorrectly or not, as in many cases the ER physician does not have much background history on a patient and is required to do due diligence in order to correctly diagnosis and treat the patient.
Imagine a middle-aged man comes into the ER complaining of chest pains. We know based on the history provided during check-in that the patient has high cholesterol and has had a previous heart attack in the last 2 years. This is noted in the medical records, but because we can only note the patient’s symptoms and final diagnosis on the claim form, our claim was down coded from a level 4 treatment to a level 2 when we ultimately diagnosed the patient with heartburn.
Does this mean the provider who performed multiple tests and spent a large amount of time confirming this diagnosis should only get paid as if he simply treated a rash? Level of service codes are far more complex and complicated than a simple final diagnosis, and the AMA agrees. So how are these companies basing down codes off a diagnosis, and not even requesting medical records to confirm the level of care provided? Many companies are now putting small print additions into their payment policies that state they will now use diagnosis codes to down code the claims without doing the extra work required to request records and review documentation in order to prove coding errors. This shifts the burden to prove accurately coded claims to the emergency medical provider by way of appeal with the records included.
Outrageous as it may sound; payers are now simply assuming providers are guilty of coding all high level of care claims incorrectly and requiring additional steps from the provider to verify the coding or accept a lower payment for the services they provided.
How are these companies getting away with such poor payment policies? What can we do to fight a payer that is automatically down coding claims? The payer says the only choice is to appeal, but this requires additional staff and is often quite time consuming to appeal an accurately coded claim, especially when the payer should have reviewed records before disputing the coding. If left unchecked, emergency medical providers could soon be paying more to bill a claim than they receive in reimbursement from the payer
Emergency Medical Billing Automatic Down Coding at 360 Medical Billing
We at 360 Medical Billing take a proactive approach with these down coded claims. As we are appealing the claims individually, we also take our complaint about the payment practice to the provider relations representative. If that fails, we file a complaint with applicable State Department of Insurance. Most states have laws protecting provider’s rights, requiring the payers to give notice of an audit on the claim, and have the records reviewed by a Healthcare professional peer before determining payment alteration. The only way for providers to get payers to follow these laws are to report the payment practices immediately. The more providers fight back, the less likely these payers will influence other payers to use similar illegal payment policies. With enough complaints to the local State Department of Insurance, providers could receive backdated reimbursement and penalty payments.
Article By Michelle Cook