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Wrongful Payer Denials: How to Handle Them Quickly


When you are wrongfully denied for a single code or entire claim, do you know what to do?

Something interesting happened last week that I wanted to share with you all. There is a local managed care HMO plan that started to wrongfully deny all new patient evaluations stating the claims were denied for: "Medicare Evaluation Codes with no functional G-codes." Yes, in an HMO, managed care plan that has nothing to do with Medicare whatsoever. I stared at the denials in disbelief. I was dumbfounded, and just thought, "This must be a mistake. I'll call them up and see what they say."

Multiple calls were made by a few of the staff and the same answer was provided; that all of the evaluation codes require a functional G-code attached to it. There were multiple requests to speak with supervisors, as this plan is not tied to Medicare at all. We kept receiving the same information, as more denials rolled in.

We looked back and found this plan started denying these claims back in October, and since it takes them 60 days to 90 days to process claims, we're just now starting to receive these.

I looked back through all of the documentation we received from them, I reviewed all of the Medicare rules and who they apply to, and I went to the plan's website to see if the provider manual had been updated without our knowledge. I even pulled the contract to see if any addendums were made that we did not sign off on. It was a treasure hunt for information.

Once our billing department exhausted all of these potential solutions and we were getting nowhere with representatives reading from canned responses on their screens, we took it to the next level. We found a resource who used to be the CEO of this plan and ran these denial reasons by him. He laughed and said, "No! They cannot ask you to go back now and change a patient's medical record." Since there wasn't any correspondence back in October letting us know this was something they were going to require, this was going against all contract regulations.

We were able to then contact the current CEO of the plan, unfortunately, she did not even understand what we were asking her. It was sad, really, that something so unscrupulous was going on under her nose, and she had no idea. When she conferred with a staff member there at the plan, they backpedaled saying they were looking for a specific modifier, not Medicare G-codes. So, we gathered up every denial that we had, put them into a large envelope and drove them out to her office. Shockingly, she had left for the day and was unavailable.

We followed up earlier this week, and humbled as she was, she said she would look into it and override the system that was causing the denials. She promised to cut us a check for wrongful denials due to this specific code. We then asked for interest on late payments. Although we all know it's just a few pennies, it's the principal of the matter - insurance companies are getting more and more arrogant with their denials and need to be held accountable.  It also makes me wonder how many other local providers are having the same trouble, but just make the denial adjustment, and don't follow up.

Because this was a local plan in the Southern California region, this method worked out well for us. We certainly still have the option to create a claim with the department of managed care so they can look further into this activity. However, if this were a Blue Cross Blue Shield or Aetna-type plan, the method would certainly be very different. But I would still most definitely fight the denial. Without specific contract changes that the owner must sign, making significant changes to your contract like this is illegal.

Most states have a governing agency that does monitor complaints from patients and providers against insurance companies. Locate yours and have that contact information on hand. Obviously, it is up to you and the resources you have available, but if you believe you are being wrongfully denied, by all means speak up! Chances are, if you're being denied, a fellow provider is as well.

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