Medical Billing problem with Blue Cross CA?

Question

Hello, I am working for a family doctor office. Recently, all our medical claims to Blue Cross CA are pending and they request us medical records for those claims. After we submit the records, Blue Cross indicate that the performed services are not medically neccessary. Thus, they only agree to pay a small portion of the total billed amount. I have called Blue Cross and they said it's their policy. We have spent so much time and effort but it does not work. Anyone has such problem like me? Please advise. I appreciate.

*** Thanks for reply. I just bill using the ICD-9 code 99213 (Office visit- limited $75). CPT codes regularly used are URI, Pneumonia, Urticaria, abdominal pain, hypertension, hyperlipidemia, asthma, Sinusitis, low back pain....or such normal sickness like that. Blue Cross used to pay us pretty good.

Could I hire a collection service to collect payment from Blue Cross in this case? Please recommend.

Answer 1

Wait, you got CPT and ICD mixed up. I don't know if that's your problem. The ICD is the condition being treated and the CPT is the procedure. They should not deny an office visit for medical neccesity. However, there are many new Blue Cross policies that now do not cover physician services at all. I have been seeing a lot of those. You need to call and speak to Blue Cross Customer Service and ask them what is going on. After you talk with them IM me and we can work through it.

Answer 2

I'd need to know what you're billing to be much help. Are you noticing any cpt or dx codes you are billing, that are more affected than other?

It sounds almost like fraud investigations. Everything can't be considered not medically necessary. Are you seeing a large volume of patients who work for the same employer?

It sounds pretty weird for a family doctor's office to run into this kind of issue. I've seen it with dermatologists, and surgeons... But, not family practice.

If they can't give you a good/reasonable answer, ask to speak with someone else at blue, like a supervisor, or someone in provider relations...
or:
Call the CA dept of insurance. They'll be able to help.

Answer 3

It really depends on what you're billing for. If you're billing sick office vists to treat strep throat or something and you're tossing in liposuction as an added benefit - they CAN tell you it's not medically necessary. But, if they're denying a throat culture for that patient with strep throat, that's a different ballgame entirely.

Without knowing more details, I suggest you get a copy of your contract with BCBS of CA and speak to your provider rep. (If you're not in CA, then go thru your local Blue for help.) Sometimes provider reps can be a big help.

Answer 4

threaten to file a complaint with the state insurance comm. sounds like you are going through a pre payment audit. apparently they dont think the documentation fits the services were performed. have the dr. make sure the notes are very detailed and type them before sending. the rule of thumb...if it cant be readm it didnt happen. good luck on the audit. keep in mind where medicare, medicaid, or bcbs goes the other 2 are sure to follow.

Answer 5

Call Blue Cross back at 800 333 0912 and tell them that you want to file an appeal. They will reforward the claim to be reviewed and reprocessed.