“Let’s Make A Deal”

“Let’s Make A Deal”

If you’re billing insurance out of network, you will eventually receive faxes or emails like this: 


Who are these people, and why are they contacting me? 

There’s a whole industry of third-party re-pricers and “passive PPO’s.” Multiplan is just one of many out there.  

A what? 

A “re-pricer” is just what it sounds like: an entity that looks at a claim and decides what is the “allowable” amount. 

Sometimes, it’s not who you think it is who decides how much you’ll be paid….. 

A “passive PPO” is an alternative provider network that serves as a backup to the original payer’s panel, another method to force a discount on out of network claims.  

Here’s the shell game: You are out of network but submit a claim to an insurance payer so that the patient can get out of network reimbursement.  (It doesn’t matter whether you’ve accepted assignment or not). The payer looks at the claim, your NPI/tax ID and sees that you are out of network. 

If the payer, let’s say it’s Cigna, has an arrangement with a third-party party re-pricer such as MultiPlan, then the claim is sent to MultiPlan by Cigna before any action is taken.  

MultiPlan’s job is to contact the doctor (YOU) and offer a discount. Keep in mind that they don’t work for free, either.  

Where is their payment going to come from? Your reimbursement, of course! 

The fax makes it sound as if you won’t get paid promptly unless you agree to the discount.  

“Your acceptance may expedite payment…” 

They mislead a lot of people into giving discounts with that language. Don’t be fooled. All states have “prompt payment” laws that specify how long an insurer has to adjudicate a “clean” claim. If the claim was sent to Multiplan, then by definition, it was accepted for adjudication and is “clean.” If the insurer doesn’t respond within the time frame, they must pay you interest. 

By telling you acceptance of these terms means you will decrease your patient’s cost share, this is true…but not the whole picture. Acceptance does reduce the amount the patient has to pay, but it does NOT put you into the network or shift the benefit level back to “in-network.” The patient will still only receive the out of network benefit level.  

If your reason for being out of network is to reject low insurance rates, signing this fax relinquishes this advantage. 

When you receive one of these offers: 

It is ok to ignore it and within a couple of days the passive PPO is required to return the claim back to the payer, who will process it as they originally would have done without the re-pricer’s involvement. 

If I have time, I enjoy calling them and (politely) telling them to get lost. I also ask them to remove the provider’s TIN / NPI from this member’s claims. Otherwise, they will continue to send offers for each date of service. 

If the patient paid in full at the time of service and you are filing for them to be reimbursed (or if the re-pricer is responding to a superbill submitted by the patient), do not negotiate; you will be cheating your patient unintentionally. 

If your patient is having financial difficulties affording out-of-network treatment, this is a legal way to offer a discount on the full billed charge after the claim is submitted.  

You *will* receive these offers even if the patient’s deductible has not been met. If you have agreed to the discount, you cannot charge the patient what you originally billed; you must charge them only what you agreed to. 

If it’s a situation where you thought you were in network for a particular patient, and then you turned out not to be, accepting a discount might smooth over difficulties from a clinical perspective. 

Be careful not to mark the box that says, “I accept a global fee agreement to eliminate the need for case by case faxes.” This puts you in network with the passive PPO…and forces discounts with any payer who chooses to hire them. You will be giving discounts where you don’t intend to – but the patients won’t get better benefits unless the passive PPO is their primary network (it can happen, with smaller payers). 

You will not receive these offers if the patient has no out of network benefits.  

Whatever your reasons for considering a deal, you can certainly attempt to get a better rate than what they first offer. I’ve found reps willing to go as high as 50% of the amount they are trying to write off.  

Re-pricers only have the power to adjust the final allowed amount; they do not get to determine what/how much is covered, paid, denied, or applied to the deductible. Nor can they quote benefits. For any of that, you must continue to work with the payer.  

Still need help? Contact Your Billing Buddy!

The Elephant in the Room: No Standardization in Telehealth Coding

The Elephant in the Room: No Standardization in Telehealth Coding

A telehealth claim during the COVID-19 Public Health Emergency (PHE) is submitted to the primary plan, a commercial plan that requires Place of Service (POS) code 02 or 10 and modifier -95. The claim applies to the deductible. The patient has Medicare as his secondary plan, and the telehealth claim is duly forwarded to Medicare without changing the telehealth place of service coding.

Medicare pays, but reduces the allowable amount due to the telehealth coding not being consistent with the PHE requirement of pre-pandemic POS code.

Providers must accept lower reimbursement for services, because The Powers That Be can’t (won’t?) get together and agree on how telehealth should be submitted? It’s the middle of 2022. Haven’t we lived with COVID and telehealth now for long enough that they should have figured this out?

It would be fraud to change coding on the claim after the primary plan considers it, right?

The opposite also happens:

A provider submits a telehealth claim to Medicare using the PHE coding.  Medicare pays correctly and forwards the claim to the secondary payer, which is not a Medigap plan. In mental health billing, some commercial insurance plans use specialty behavioral health vendors known as “carve-outs,” where the entity who pays mental health claims is independent of the insurer who handles the medical benefits. This plan was one such. Because non-Medigap plans do not have to follow Medicare guidelines, the secondary payer in this case didn’t adjudicate the claim but denied it back to the provider stating they were not the correct payer. The provider is then required to file a manual claim to the secondary payer’s behavioral carve-out to obtain reimbursement.  This was done without changing the telehealth coding, and the behavioral plan denied the claim: INCORRECT CODING. An appeal was submitted explaining that the provider was following Medicare guidelines, and included a copy of Medicare’s directive for coding PHE telehealth claims. The appeal upheld the denial: “the telehealth coding is incorrect.”

The provider was acting ethically by not adjusting coding after the fact. Now she must lose out on the reimbursement – because it certainly would not be fair to charge the patient.

Is there a solution here?  Can coding be changed ethically? Is it fraud? Abuse?

I asked Chad Schiffman, Director of Compliance and Risk Management at Healthcare Compliance Pros.

He first clarified the difference between “fraud” and “abuse,” which I think is an important distinction. In his words,

“Medical billing fraud and abuse arises mainly due to medical coding and

billing errors which lead to improper reimbursements. Fraud is a deliberate

deception that results in an unauthorized payment, while abuse is failing to

adhere to accepted business practices.”

It seems that we’re not contemplating fraud here – if you provided a telehealth service, that’s what you provided and there is no deception.

Mr. Schiffman agreed.

“It would not be considered fraudulent if the medical record

documentation supports the … claim being submitted, and the

code was just being updated with a corrected code.”

But he cautioned that providers need to:

1) refrain from altering the documentation after the fact, just to support a corrected claim; and

2) make sure that the codes on the corrected claim do in fact reflect the medical record.

Abuse seems to be the issue here: failing to adhere to accepted business practices. in this instance, accepted practice is to keep codes consistent between the primary and the secondary payer.

I also asked Mr. Schiffman about the two scenarios above.

“I discussed these scenarios with our Coding and Auditing Manager. On the

first scenario, she pointed out because it applies to the deductible, she is

uncertain if Medicare will allow the coding to be changed and resubmitted.

We looked for guidance and came up blank on that. She recommends

contacting the MAC, explaining the scenario, and seeing if they allow a

corrected claim after it was already submitted to the commercial payer.”

“For scenario 2, while we do not see an issue from a compliance perspective

correcting and resubmitting the claim to the secondary payer, we would

recommend contacting the payers directly and seeing if they allow it or

what their process is.”

Ok, so if the best minds in Compliance “came up blank,” then how is a solo provider, with no coding background and no staff, supposed to get it right?

Good point! My advice: proceed with caution.

While contacting the MAC or a private payer seems to be a logical step, most likely the customer service rep will tell you that they are not allowed to tell providers how to code. They will say “code according to your documentation and best practices.” Which puts you right back where you started. And even if you did, by some chance, get a CSR to answer you…what guarantee do you have that this rep gave you the correct answer? In an audit, would that stand up?

My recommendation is to play it safe: unless the MAC or private payer is willing to answer your question and give you permission in writing … then, don’t.

Yes, it’s unfair, and it sucks not to be fully paid – but the consequences of altering coding between a primary and secondary payer could be far worse.

Tired of being short-changed?

I don’t blame you – it’s unjust.

Are the professional organizations aware of the elephant in the room? What are they doing to rehome him back into the wild, and represent you?

Avoiding the Medicare “Advantage” Traps

Avoiding the Medicare “Advantage” Traps

A patient comes to you, says I have Medicare primary and then United Healthcare. You bill in that order, but are puzzled when Medicare denies the claim with the following reason code:


Now what do I do?

You are a counselor or marriage and family therapist who cannot accept Medicare. A patient starts treatment and gives you an Aetna card. Aetna pays you – but a year later they claw back the money, stating you weren’t entitled to it because your license isn’t eligible for Medicare. But when you called to verify benefits, you were told you were in network and the patient had benefits to see you.

The patient had Aetna! What does Medicare have to do with anything?

You have several patients with BCBS and are in network. However, your claims come back paid at a different (lower) rate than usual, plus a small deduction marked “sequester.” Over time, it’s added up to hundreds of dollars. You try to figure it out and get nowhere.

No one seems able to explain it and they pass me around to different departments.

You are a Medicare provider. You’ve been seeing a patient with Medicare and a supplement for years. Suddenly, Medicare denies your claims, stating they aren’t the correct payer. You don’t understand.

How can someone have Medicare, stay retired, but then suddenly have something else for insurance?

WHY do they make this so confusing?

The one thing that all these scenarios probably have in common is that the patient may have what’s known as a “Medicare Advantage” policy.

The mental health community is often confused about what Medicare Advantage is and isn’t – so Your Billing Buddy is going to set you straight, because it often seems like no one else will.

In brief, without any technicalities, judgments, or public policy justifications/disputes for the existence of the Medicare Part C program (AKA Medicare Advantage) … these are alternative commercial plans that Medicare beneficiaries are allowed to choose. Once enrolled in Medicare Advantage, any claims to Original Medicare will deny with the above reason code that Medicare is not the correct payer.

(An exception – because there must always be one, right? – If your patient is hospice enrolled, you will go back to billing Original Medicare, with a hospice modifier).

In 2021, according to the Kaiser Family Foundation healthcare research, 42% of Medicare beneficiaries were enrolled in Medicare Advantage.

That was about 26 million people – so if you haven’t yet seen one of these common scenarios in your practice, you will. It’s only a matter of time, especially given the aging demographics of the population.

So how do I protect myself from denials, clawbacks, and fee erosion?

There are only two things you need to do to avoid the tricky trap of Medicare Advantage:

Get their Insurance Cards

After 24 years as a biller for mental health services, I’m still shocked by how many providers (and their EMR systems) do not feel it necessary to capture this information. Insurance cards have all sorts of logos on them that provide valuable information.

All Medicare Advantage cards are easily identifiable. Terms such as Medicare Advantage, A Medicare Private FFS Plan (fee for service), or [Payer name] Medicare are usually prominently displayed. Also, look out for cards marked Dual and/or SNP – these are Medicare Advantage plans for patients who are also eligible for Medicaid and combine both benefits into one policy.

Some examples (there are many)

Verify Eligibility

Read the fine print of the section that shows you the funding source of the plan.  (Although a card like the above would tell you all you need to know).

So ok, they have Medicare Advantage. Now what? Can I take this plan?

In order for you to be paid for your services, as of 2019 you must be an eligible, enrolled Original Medicare provider in order to be paid by a Medicare Advantage plan.

But: You do NOT have to participate in the network of the Medicare Advantage payer offering the benefits. If you aren’t, you will be paid 100% of the Medicare fee schedule. If you signed the CMS-460, you cannot balance bill. Non-participating providers may bill up to 115% of the Medicare allowable rate, just as they can with Original Medicare.

In fact, it may be preferable NOT to contract with Medicare Advantage plans. The Original Medicare allowed amount is typically anywhere from 10-40% MORE than you would be paid if you were a participating provider in a Medicare Advantage network.

The sequester applies to reimbursement from both Original Medicare and Medicare Advantage, so while it is not part of the reason why Medicare Advantage plans pay less, it is a clue that your patient with a commercial plan in fact has Medicare Advantage.

Caution: there are Medicare Advantage plans that do not offer out of network benefits – so you have to verify if there is out of network coverage. Medicare Advantage patients who have no out of network benefits have the same choice as any other patients with policies not featuring out of network coverage: self-pay or choose another provider.

Original Medicare providers are under no obligation to participate in Medicare Advantage plans.

Nor do they have to opt out in order to accept a Medicare Advantage patient who wishes to self-pay. Also, no ABN is required for Medicare Advantage patients.

Providers who are opted out from Original Medicare can NOT be paid by Medicare Advantage plans.

I find that the biggest trap of all with Medicare Advantage, is the fact that patients don’t always understand it. When they call for service, they give incorrect information, and busy practitioners without a lot of support tend to take patients at their word. Remember, your patient isn’t trying to deceive you – but this stuff is hard to understand, or you wouldn’t be reading this blog. So, understanding your patient’s plan type could save you hundreds if not thousands of dollars later in denied or clawed back claims.

No Surprises Act: Death by Attestation

No Surprises Act: Death by Attestation

By now, we’ve all heard more than we probably want to about the No Surprises Act and Good Faith Estimates. But there is another part to the whole Consolidated Appropriations Act puzzle that concerns mental health professionals.


What we think of as the “No Surprises Act” is not a law unto itself. No Surprises, along with several other healthcare provisions that will affect practices in the years to come, was bundled into a huge spending bill passed on December 21, 2020, titled the Consolidated Appropriations Act.

An interesting factoid, courtesy of the Senate Historical office: The CAA is the longest bill ever passed by Congress, to date. It tops out at 5,593 pages.

I wonder how many members of Congress actually read all 5,593 pages …

This blog concerns the tightening of provider directory regulations.

There are regulations for provider directories? Really?

Yep. And they aren’t new, either.

As of January 1, 2016, CMS became legally authorized to fine Medicare Advantage plans up to $25,000 per beneficiary if the number of errors in network provider directories exceeded a certain threshold. It doesn’t take a math major to realize that even 50% of this penalty would be a huge chunk of change out of a health insurer’s pockets.

The effect on practitioners began slowly, without much notice or fanfare. You’ve all been subjected to it, probably without ever realizing why (other than to moan about what an annoying pain in the rear it is). Services like CAQH, Availity, and the insurance payers themselves began sending around emails: VERIFY YOUR DIRECTORY ENTRY NOW.

Later, those same emails started to become more nagging, almost threatening, in tone: YOUR QUARTERLY ATTESTATION IS NOW DUE. ACT NOW TO AVOID DIRECTORY REMOVAL.

And. They. Just. Kept. On. Coming. From everyone.


Wait, what? They can do that?


Prior to January 1, 2022, directory suppression of providers who did not re-attest was at the discretion of the health plan. To my knowledge, most plans never suppressed names. The only plan that I have encountered which did, was United Healthcare.

At least on the national level. Some states (California, for one) did have stricter requirements prior to the Consolidated Appropriations Act.

But as of January 1, 2022, the No Surprises Act mandates:

  • Health plans must refund enrollees the additional costs for out of network care if they paid an out of network bill for services & can show they went out of network because of inaccurate plan directories. Yes … Really!
  • Health plans must pay an out of network claim with in-network level cost-sharing, if the patient saw an out of network provider due to a directory error. I would imagine that the patient would have to do some serious advocacy on their own behalf, though.
  • In this event (an out-of-date directory) the out of network provider must not bill the patient more than the in-network cost-sharing. No balance-billing.
  • Providers can require health plans to remove them from the directory at the time they terminate their contract.
  • Health plans must have a regular method of verifying provider directory information.
    • Payers must update their directory within 2 business days of receiving new information.
    • Payers must confirm with providers every 90 days to re-verify accuracy of information.
    • Payers must suppress provider information from directories if attestations aren’t received every 90 days. (Note: suppression does not affect claims for ongoing patients. Those will still be paid at the in-network rate. It’s the online directories that will not list your name. Maybe you don’t care …. But if an existing patient changes insurance, only to consult their new directory and discover that you are no longer listed…then what?)

Certainly, the need for accurate directories is important. Nor would verifying, or attesting, be a huge problem on the provider side, if a way existed for providers to go one place once per quarter and disseminate the same information to all plans. (Wasn’t that the original point of CAQH?) The burden comes with having to go multiple places online to provide the same information, take phone calls, fax or email forms. It’s a burden even for providers who have staff – because employees must be paid. This is employee time that could be devoted to patient care or billing.

Further reading, if you’re so inclined…



We won a great victory – Does anyone know about it?!?

We won a great victory – Does anyone know about it?!?

Transaction #: 123456789

Card Value: $1,500.00

Date: April 1, 2021

When I see this…

  • Why should the clinician have to pay to be paid?
  • Why do doctors have to spend time manually entering all these – there’s not even a QR code or a way to swipe them! Time is money too!
  • How much do you want to bet that the insurance company and Mastercard/Visa are splitting that merchant fee as a “kickback?”
  • They are making me log onto 10,000 different websites to get my remittance information for posting, rather than sending it to me in the mail or via my clearinghouse/software! That is SUCH a waste of my time.
  • They’re saving themselves time and money, at the doctor’s expense!
  • Payers know the doctors don’t have time to figure out these complex enrollments, so they count on people giving up and charging the virtual cards – and they are right.

NO … I’m not opinionated or anything…

Since 2014 when I received the first “Virtual Credit Card” (yes….it really WAS that long ago), the number of payments received in this format has proliferated like, well …..Tribbles.

It used to just be an annoyance, but all you had to do was call and they’d (grudgingly) send you a check.

Now, here’s what happens:

  • Plans will refuse to allow enrollment in automated remits (ERA) unless the provider agrees to accept VCC or direct deposit, often from third-party intermediaries.
  • Often the direct deposit option requires a fee also, which currently can be as high as 2.5%.
  • Some plans refuse to pay by check at all. It’s either direct deposit or virtual card. Even if you’re out of network, out of area, or you only do business with them once every 5 years. Doesn’t matter.
  • If they do agree to pay by check…it can take the check months to arrive, after several phone calls to follow up.
  • The direct deposit registration process is often handled by third-party intermediaries and is incredibly complex and takes months. Which, frankly, I don’t understand. I go to my power company’s website and pay my bill in under 5 minutes simply by entering my routing & account #’s. So why does direct deposit registration with payers take months?

Now that I’ve raised your blood pressure to stroke levels….I have amazing news! We have won a victory over this abuse.

No way, really????

I know, right? Here’s how we fight these virtual cards and unreasonable-fee intermediaries:

On March 22, 2022, CMS quietly issued the following two guidance letters. In dry HIPAA-ese, they upheld providers’ rights.

For Health Plans: https://www.cms.gov/files/document/guidance-letter-vcc-eft-era.pdf

For Health plan vendors/business associates: https://www.cms.gov/files/document/guidance-letter-business-associate.pdf

Help! Is there an English version? I clicked the links, but what does all this gobbledygook mean? What do I need to do?

(Click here for the explanation and permanent solution to this pernicious skimming away of your hard-earned reimbursements.)

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