Did you ever have insurance reimburse less for therapy because of the multiple procedure payment reduction?

[Anonymous]

Our OT's superbills list three different codes for each session. They are out of network so we submit superbills to our insurance. We are getting reimbursed, but at a lower rate because the second two codes get reimbursed at the 50% rate.

I don't know whether to let this go or discuss with the OT practice so see if they can write the superbills differently. I definitely don't want them to think we want them to commit insurance fraud. But it also seems like a BS reduction and our insurance company has lied to us before.

[Anonymous]

PT here. I am surprised this is the case. Usually they reduce to 50 percent when the same code is used during a session more than once which is why three codes are used. It usually gets more coverage than less. Maybe call and ask what would happen if three of the same code was billed in the same session. Just pick one of the three and ask. Maybe 97530.

[Anonymous]

Anonymous wrote:PT here. I am surprised this is the case. Usually they reduce to 50 percent when the same code is used during a session more than once which is why three codes are used. It usually gets more coverage than less. Maybe call and ask what would happen if three of the same code was billed in the same session. Just pick one of the three and ask. Maybe 97530.

Thank you for your response. It sounds like this may be worth exploring further. In the past, the insurer has declined to provide any information about hypothetical reimbursement when contacted about it, so I think I will need to do my own research on this to see if it is worth appealing and on what grounds.

[Anonymous]

They should be able to tell you what reasonable and customary is for each code. That should tell you the max amount they consider per code and then you have your percentage that you have to pay OON.
I think you could also show the OT the insurance response and they should be more than willing to work with you to recode. There is so much overlap in codes that usually they just pick the big three to divide it up.

[Anonymous]

Anonymous wrote:They should be able to tell you what reasonable and customary is for each code. That should tell you the max amount they consider per code and then you have your percentage that you have to pay OON.
I think you could also show the OT the insurance response and they should be more than willing to work with you to recode. There is so much overlap in codes that usually they just pick the big three to divide it up.

I have asked them to do this before, and they declined. I have spent hours on the phone trying to get basic questions answered and they stonewalled me and gave me incorrect information until I escalated the issue. I refuse to call them anymore. I might send a message via the portal and see what they say before I appeal.