Are your carriers forthcoming with fee schedule information?
Incorrect payment appeals must be backed up with accurate fee schedule information. However, payment calculations may be affected by several variables including fee schedule modifications, bundling/coding logic and negotiated terms specific to your organization. Therefore, when a claim appears to be underpaid, your appeal may need to seek disclosure of how the payment was calculated. Start with a brief explanation regarding the anticipate payment. Once your expected payment is outlined, ask the carrier to disclose why payment was not made as expected using language such as the following:
Our review of the provider contract does not reveal any language justifying the current level of payment. In order to assess the accuracy of payment, we request your response regarding how the payment was calculated and what portion of the fee schedule was utilized. It is our position that if terms of the contract are in direct conflict, the higher reimbursement should be allowed. As you are likely aware, many courts have ruled that managed care contracts are contracts of adhesion and that the organization responsible for drafting the contract wording can be responsible for unclear and ambiguous terms.
Most states have managed care protections, which require managed care organizations to disclose the fee schedule upon contract finalization or upon request by participating providers. Furthermore, states may impose additional restrictions on modifying the fee schedule without prior notification. It is, therefore, important to obtain the fee schedule and keep track of any modifications and the respective implementation dates. For codes that are individually negotiated by your organization, written documentation must be disseminated to the billing and appeal staff so that this documentation can be easily attached to appeals.
Notification language should be negotiated that prohibits fee schedule changes without advance notification to the provider. It is also important to attempt to limit fee schedule changes to an acceptable time span, such as yearly.
Once accurate, up-to-date fee schedule information is obtained, providers with high volume billing will want to consider contract management software which can identify underpaid claims based on loaded fee schedule information.
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