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?