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CONSULTATION BILLING: Report to Provider Requesting Consultation

Health Insurance Companies Process 1 in 5 Claims Wrong

There are many requirements that must be fulfilled to properly bill for a consultation. One item that CMS and insurance carriers have been looking at is the reports sent to the provider requesting a consult.

When sending letters back to a provider who requested a consultation for a patient, make sure that your letter does not use the words referred or referring.  A requirement of a consultation is sending a report back to the requesting provider. Usually reports or letters start out as saying “Thank you for referring Mary Jones . . . . .”.

The government and some payers are viewing the word refer in the managed care definition of referring a patient to a specialist and not of asking a specialist for a consultation.  In other words, it is seen as a transfer of care and not a consultation request.  Why do they do this? Because consultations pay more than office visits.

When auditors review the letter sent back to the requesting provider, if the word refer is written they then may lower the code from a consultation to an office visit which represents a reduction in payment. The practice will be required to reimburse the overpayments.

When composing a letter to the provider requesting the consultation start out with something such as, “Thank you for allowing me to participate in the care of Mary Smith.”  By wording your letter in this fashion you steer clear of at least one obstacle in getting paid for the work you have done.

If you need help getting paid for what you do? Capture Billing can help.  CLICK HERE

is a 20 year veteran of healthcare having managed medical practices. He advises medical practices, physicians and practice administrators on how to run their practice and manage their medical billing and revenue cycle management. Manny speaks, blogs and makes videos at www.CaptureBilling.com, a blog that is tops in the medical billing and coding field. READ MORE

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The analysis of any medical billing or coding question is dependent on numerous specific facts -- including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies (as well as coding itself) are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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