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It is  usually  1-­‐5  minutes  over  or  under.    Occasionally,  the  visit  will  be  significantly  longer  than  the  time  scheduled  when  the   doctor  feels  that  more  time  is  necessary.    The  provider  does  not  waive  his  or  her  fee  for  this  additional  time.         There  are  exceptions  to  the  fee-­‐for-­‐time  guideline:    Several  medical  procedures  have  pre-­‐set  fees,  which  are  explained  to   patients  prior  to  scheduling  their  procedure.    An  example  would  be  an  appointment  for  PRP  (platelet-­‐rich  plasma)   therapy.         Q:        My  doctor  has  recommended  PRP  (platelet-­‐rich  plasma)  therapy  to  treat  the  arthritis  in  my  knee.    Will  my   insurance  cover  this  procedure?   A:        Most  insurance  carriers  have  their  reimbursement  policies  posted  on  their  websites.    At  the  time  of  this  writing,   Aetna  and  Carefirst  both  have  policies  of  non-­‐coverage  for  PRP  because  it  is  still  considered  by  the  medical  establishment   to  be  experimental/investigational.    We  encourage  you  to  contact  your  carrier  and  find  out  for  sure  if  they  cover  the   procedure.    The  CPT  code  for  PRP  is  0232T.    It  is  also  possible  that  the  injection  itself  may  be  covered.    For  example,  the   CPT  code  for  an  injection  into  a  tendon  or  ligament  is  0232T,  and  the  CPT  code  for  arthrocentesis  (an  injection  into  a  joint   space)  of  the  knee  is  20610.      

Insurance Denials     Q:        Why  is  my  office  visit  charge  being  denied  as  “integral  to”  (or  bundled  with)  the  more  complex,  primary   procedure?   A:        If  the  “-­‐25  modifier”  is  attached  to  the  “office  visit”  (circled,  if  you  are  filing  yourself),  the  insurance  company’s   decision  to  deny  is  an  adjudication  error;  in  other  words,  your  insurance  carrier  did  not  process  this  claim  correctly.         Q:        How  do  I  appeal  when  the  office  visit  is  bundled  with  another  procedure?   A:        You  can  usually  handle  this  request  for  redetermination  with  a  phone  call  to  your  insurance  provider.    Here  is  an   example  of  what  you  could  say:         “My   office   visit   was   billed   with   the   “25-­‐modifier”   to   indicate   that   the   office   visit   was   a   distinct   and   separately   identifiable   service   from   the   medical   procedures   my   doctor   performed   on   the   same   date     (probably   Acupuncture   and/or   Osteopathic   Manipulation).     My   claim   was   inappropriately   denied   (or   bundled)   because   the   “25-­‐modifier”   was   incorrectly   disregarded.     Please   send   this   claim   back   for   reprocessing.”     Q:        I  paid  the  Kaplan  Center  to  file  my  insurance  claims  for  me  and  my  claim  was  denied.    Does  my  filing  fee  include   appealing  my  claim?   A:        The  claim-­‐filing  fee  covers  the  cost  of  having  the  Kaplan  Center  to  file  a  “clean”  claim  with  your  insurance   carrier,  meaning  we  ensure  that  the  claim  is  correctly  coded.  We  also  submit  the  form  in  the  format  preferred  by   your  insurer,  so  that  it  will  be  processed  more  accurately  and  quickly.    Claims  denied  for  contract  limitations  are  not   the  responsibility  of  the  Kaplan  Center  and  may  not  stand  up  to  an  appeal  by  the  patient/subscriber.    Claims  denied   in  error  due  to  poor  insurance  company  adjudication  practices  also  are  not  the  responsibility  of  the  Kaplan  Center.     These  claims  must  be  appealed  either  by  a  telephone  request  for  redetermination  or  by  written  appeal.    Please  be   sure  to  file  your  appeal  within  the  timeframe  prescribed  by  your  insurance  carrier;  otherwise,  you  may  lose  your   right  to  appeal.  When  appealing  by  phone  always  document:       The  date  you  called,     The  name  of  the  person  with  whom  you  spoke,     What  was  said,  and     Ask  for  a  reference  number  for  the  call.     If  you  receive  your  insurance  through  your  employer  and  you  find  your  claims  are  being  routinely/repeatedly  denied,  you   should  report  the  problem  to  your  company’s  Human  Resources  Department,  so  they  can  intervene  on  your  behalf.     Otherwise,  you  should  consider  finding  a  new  insurance  carrier.     Q:        I  usually  file  my  own  claims,  but  sometimes  I  ask  the  Kaplan  Clinic  to  file  my  claims  for  me.    When  I  do,  my   claims  seem  to  get  paid  faster,  while  those  I  file  are  processed  more  slowly  and  sometimes  get  denied.    Why?  

billing-insurance-faqs  
billing-insurance-faqs  
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