Changing Diagnosis Codes to Get Claims Paid!!

Have you ever had a patient call you and tell you that the reason their claim went to coinsurance, deductible, or was denied for non covered services, is because you used the wrong codes on the claim?

This happens all the time. Its inevitable that the patient who receives a bill when they weren’t expecting too, calls the insurance company member services area and questions why their claim wasn’t paid. The most amazing thing about this is that the customer service representative at the insurance company itself tells the patient that if another code was used it would have paid and to
have the doctors office resubmit the claim.

The only way a claim should ever be changed is if there truly was an error and the record must support the change. If the record doesn’t support the change it must be appended with the correction.

You must always bill what was actually done and your records must always support that. The patient needs to understand this concept as well. The patient also needs to understand and take responsibility for understanding their policy and benefits. The medical office sees thousands of patients and cant possibly know every policy coverage.

The medical office risks audit and fines if they cannot support changes in claims or if medical records don’t support what was billed.

When this unhappy patient calls with this dilemma explain what you can and cannot do and why. If there is a hardship for them to pay, work with them by providing discounts and payment plans that they can keep current with.

Insurance company customer service representatives also need to be trained with factual responses that don’t incriminate the medical office for doing something wrong, when in fact they are doing something wrong by advising that a diagnosis be changed. These representatives should be reported so that this practice doesn’t continue.

Do the right thing!!! And..call us if you need any help…1.877.666.5279

Leave a Reply

Your email address will not be published. Required fields are marked *