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We are having issues with the medical insurance companies paying claims based off very low allowable fees. We are out of network however they are stating they are basing their out of network fees on Usual & Customary fees. However when we call to verify benefits initially, they are unable or unwilling to give us their allowable out of network fee for each code. Consequently, when the claim is paid it is significantly reduced from our fees and the patient ends up with a high balance.
Does anyone else experience this problem and how do we fix it? We are experiencing the same thing with TMD claims.
I did see that for our last claim to BCBS, we did not use a modifier for E0486 however they paid it based off the rental allowable fee. Do we need to use the NU modifier at all times for this code? Is this just BCBS or should we be using modifiers for all medical claims/insurance companies? Appreciate your help.
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Hi willowcreek!
Unfortunately, insurance companies will always pay claims based on their "allowed" or "usual and customary" fees, and as you stated, as an out of network provider, these amounts are largely unknown to you. This is one way insurance companies incentivize you to join their network and become an in-network provider! When you are in-network, you know your contracted rate and can accurately estimate a patient's out of pocket expense. The obvious downside is, you will have to accept your contracted rate (which you can attempt to negotiate the amount of, by the way!)
Without contracting to be in-network, your best way to estimate reimbursement out of network is to look at EOB from already processed claims. You can find the allowed amount on the EOB, or at least get a good idea of what it is! (**note - every once in a while - you can ask for what is called a "courtesy medical estimate". If you send the insurer a list of code and fees you will be billing with appropriate Dx code and documentation - SOMETIMES they will supply you with an out of pocket estimate for the patient based on your fees vs their allowed amounts, but you may need to enlist your patient's assistance for this request.)
And yes, we recommend to always use the modifier NU when billing the code E0486. Oral appliance cannot be rented, and NU indicates it is new equipment!
Hope this helps! Let us know if you have any additional questions.
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 1 user thanked courtneydsnow for this useful post.
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Thank you for your help. I have been looking at EOB's for past patients to see if we can find what the standard allowable fee is for the various medical insurance companies. The problem is that it is not always the same. For example, for two patients United Health Care allowed $739 for 70486 and then UHC only allowed $276.58 for the same code, two different patients.
Can we go back to them, show the discrepancy and get them to pay the higher amount?
Lastly, do you recommend the modifier NU for code S8262 as well?
Thanks!
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Hi willowcreek!
That is interesting, I would definitely use the first processed claim as an example and ask them to adjust their second amount (that has worked for some clients in the past)......was is the same diagnosis code as well? How far in between patients? (fee schedules can change....but generally not that drastically!)
And as for using NU with the S code - we don't see this used, NU is generally reserved for DME codes (E0486 is a DME code)
Hope this helps! Let us know if you have any additional questions!
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1 user thanked courtneydsnow for this useful post.
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Thank you! We will try that. As for the S8262 code, any suggestions for modifiers? We have seen them pay as little as $70 for this code when our cost is much higher. Thanks again.
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Hi willowcreek!
There are no suggested modifiers that will help increase reimbursement amounts for S8262. $70 is very low though. Are you selecting checking "yes" or "no" on the claim form for outside lab in box #20?
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