Are payers playing fair when it comes to evaluating cases?
It seems that every day there are articles or legislation in the state and federal government intended to put a stop to so-called “surprise bills.” Fingers are pointed, blame is placed, and causes are cited to support particular positions.
Surprise bills are not just a Prudent Layperson Standard issue, a physician versus facility participation issue, a network contracting issue, a fair payment argument, exorbitant charges, or abuse of emergency services. Those are just some of the possible causes, and they should be thoughtfully evaluated and addressed. However, the cause not getting nearly enough attention is payor coverage determinations that fly in the face of the Prudent Layperson Standard, common sense, contract provisions, and ethical conduct.
More and more media outlets are profiling these cases that cause immeasurable stress and unreasonable financial burden on unsuspecting patients. Add the well-known and oft-lamented factors of patients with no contractual expertise, explanations of benefits that do not make sense to patients, medical bills that are extremely complex, the difficulty of speaking with a human at an insurance company who is knowledgeable and helpful, and the seemingly endless need to start over with every “customer service” contact, and the scope of the issue becomes clear. The fight for fair coverage can take money, years, and a massive time commitment: something many people do not have.
I have to ask if this is purposeful insurance plan behavior, done knowing full well that many or even most patients can’t or won’t fight the battle.
This issue hits home for me, as I have watched a good friend fight this battle since July 30, 2016. On that day, his 16-year-old daughter was invited to join the family of a good friend for a day of boating. A tubing collision between the friends knocked out her front teeth.
Her BlueCross plan covered the emergency visit because it was a severe injury sustained in an accident. Accidents resulting in injury were clearly covered under the contract. But then the trouble began. Although it was blatantly obvious that additional interventions were medically necessary and were a direct result of the accidental traumatic injury, BlueCross took the position that teeth are cosmetic. Typical of most plans, cosmetic services are not covered.
Appeals fell on deaf ears, although multiple letters inquired if her subsequent surgeries and bone grafts were related to an accident. Eventually, her father hired an attorney, and in August 2017, that resulted in partial coverage, exclusive of new teeth. More appeals followed. More denials for timely filing and cosmetic services continued. Weekly phone calls by her father requesting redetermination became the norm. At long last, BlueCross covered what they should have from the beginning and made payment in September 2018.
Unlike many of us for whom it would be impossible, her father managed to pay the $27,109.86 in medical bills out of pocket while insurance resolution was pending. Yes, he eventually got refunds, but in addition to the mental, emotional, and financial strain, it directly impacted how much this single father could financially help his triplets when they graduated and were exploring colleges.
In my opinion, no legislation or discussion of surprise bills is valid without addressing this scenario. Multiple insurance companies in multiple states are under fire for practices that defy reason and ethical conduct. This beautiful girl’s journey is attached in pictures; you be the judge if having front teeth was just “cosmetic.”
Programming Note:
Listen to Matthew Albright report on this issue live today on Talk Ten Tuesday, 10-10:30 a.m. EST.
Clinical documentation integrity (CDI) professionals work in a variety of settings, and although I mostly focus on topics related to hospital inpatient billing, this week
With so much focus within the federal government on abuse, fraud, and waste, I thought it might be helpful to review a couple of federal
Please log in to your account to comment on this article.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
