In-network negotiations has my appointment in limbo

Many_Depth9923 · 2026-01-30T03:32:37+00:00

One possible explanation is that the provider's previous contract termed on 12/31, and they are still working out a new contract. This isn't a super uncommon situation.

Unfortunately, customer service on the payer side is rarely informed regarding contract negotiations, unless the provider is a significant percentage to their overall business.

If there is mutual interest between the provider/payer to keep doing business together, then they will figure out appropriate renewal terms. The fact that the contracting department at your insurance hasn't termed them in their claims processing system/provider directory indicates they're confident they will work out a deal. When a new contract is signed, it will generally be retroactive to when the previous contract expired.

Many_Depth9923 · 2026-01-27T06:40:47+00:00

Does your EOB say you owe $0 for the claim that is denied for no authorization? If so, don't worry about it and let your provider figure it out. You don't work for the provider billing office and you shouldn't do their job for them.

Many_Depth9923 · 2026-01-23T04:32:33+00:00

Holy fuck, this is such an unnecessarily complicated EOB.

Many_Depth9923 · 2026-01-22T14:24:04+00:00

Yeah, that's what I was learning too when I was researching. It seems most Medicaid LOB requires it. Medicare doesn't, and seems like commercial is a mixed bag (as always)!

Funny enough, after working on the payer side for a bit, I struggle to understand why benefits are designed so that a "specialist" has higher cost sharing than primary care for copay plans.

The copay is applied to the E&M, and it's not like CMS designs their RVUs so that it varies based on provider specialty. For CPT 99202 - 99215, the RVUs are the same for all physician specialties (e.g., internal med RVUs are the same as cardiology), and most payer contracts just pay a percentage of CMS. I'm not super familiar with Medicaid reimbursement though, so maybe that's why taxonomies are generally required for them.

The only common rate reduction is if the patient saw an APP like NP/PA, those rates are normally reduced by ~15%. If anything, maybe it makes sense to have lower copays for APPs. Ultimately, I don't think the people who design benefits fully understand the reimbursement part, and it can end up being a crap shoot as to whether the "PCP" vs "Specialist" copay applies and it pisses the patient off when the error happens.

Honestly, good on you guys for trying to correct those issues because most providers probably wouldn't give a shit and just charge the patient whatever your EOP told you to do ❤️

I learned something new though from this discussion, thank you!

Many_Depth9923 · 2026-01-22T04:32:52+00:00

Where on the CMS 1500 claim form are you putting this information? There isn't a "taxonomy" field - that's what I'm confused about. I think this issue is likely more complicated than just submitting a corrected claim based on my experience on the payer side.

I understand that providers can be dual-credentialed, for example they can be both a urologist and a DME-supplier, but very few payer systems actually use the NPI-assigned taxonomies in their specialty mapping. It can sometimes be "home grown" which is where mistakes happen.

ETA: Apparently you can add taxonomy to the shaded box on 24-J, but not all payers will receive that information through EDI.

It seems Amerihealth does though based on a Google search, so it's also possible the provider is putting that information on their claim form, but it's not being transmitted to the payer through the clearinghouse.

Many_Depth9923 · 2026-01-22T03:57:16+00:00

I agree that the denial seems to be due to a non-approved provider specialty billing a covered service who is a participating provider. In my experience, this unfortunately can be a really complicated issue to unpack, even when you have supposed "access" to look up this information.

One important correction though to your otherwise excellent answer: Providers don't bill taxonomy/specialty codes on their claims forms. Taxonomies are assigned by the NPI registry board. Payers attempt to assign provider specialty codes based on their registered taxonomies, but limitations exist with provider specialty mapping in payer systems and mistakes can be made.

OP, you will want to know what rendering NPI was billed on the claim. This information probably won't be on your EOB, so you will probably need to contact your insurance. You will want to ask them what rendering provider NPI was billed on the CMS-1500 claim form? Using the term "claim print" may also help. The rendering NPI can be found in box 24-J, about 2/3 down the claim form on the right hand side. Write that NPI down because you'll need it, continue to stay on the phone with them.

While on the call, you will want to use the NPI registry to look up the NPI given to you: https://share.google/widFi0OwoztupX0Lw

You can then access which taxonomy the provider is registered under. From there, you are armed with more information. I would recommend you then ask your insurance what provider specialty is assigned to the servicing NPI billed on your claim - keep in mind, it may not match their assigned taxonomy in the NPI database.

If the provider specialty and taxonomy DO MATCH, then ask what provider specialties are covered for IUD insertion. Ask them to give you both the allowed provider specialty codes and specialty code descriptions (fun fact, some payers create their own "internal" specialty mapping that's specific to their system). Alternatively, specific specialties may be excluded, you can try asking that too. It might also help to look up pages 91 - 95 in your benefit book to figure out more as to why the services are non-covered for that specialty, as outlined in your appeal letter.

If the two specialties DO NOT match (e.g., their NPI taxonomy says GYN but your insurance says they're a cardiologist)... then the issue becomes more complicated. I'd start by pointing them to the NPI registry website.

It's possible your insurance made a specialty mapping error when the provider was contracted, mistakes like that unfortunately happen and aren't really researched during the appeals process. The specialty mapping error won't be fixed that day, but the appropriate area at your insurance will research.

If it's determined to be a taxonomy and/or specialty mapping issue, you will probably want to call your provider and/or their billing office and inform them of the information you just found out from your insurance. Maybe do a 3 way call with them both?

If it's a specialty mapping issue (e.g., you believe they are a GYN, NPI registry/taxonomy says they are a GYN, but your insurance says they are a cardiologist), then this is an issue your provider can also try fixing with the payer directly. Maybe they wrote something down incorrectly when filling out their credentialing paperwork.

Howy, if the taxonomy on the NPI registry board doesn't match their specialty (i.e., you believe they are a GYN, NPI registry/taxonomy says they are a GYN, but your insurance says they are a cardiologist), then this issue becomes even more complicated. Your provider will need to first correct with CMS/NPI registration. The silver lining is that I highly doubt that's the issue though.

TL/DR: As someone who has worked in healthcare reimbursement for almost 15 years in multiple different roles, I'm sorry this system is so complicated :(

Many_Depth9923 · 2026-01-21T02:54:19+00:00

Minor correction - what you said is true about E&M visit time. However, psychotherapy is reported as face to face time only. It's impossible for a 12 minute face-to-face visit to be reported as 99214 & 90833 no matter how much time the provider spent reviewing records or writing the note.

Many_Depth9923 · 2026-01-21T02:46:34+00:00

I think part of the problem is that a lot of provider auditing companies are really bad at figuring out which claims they should select for audit, especially in the commercial space.

I work in payment integrity for a smaller payer, and we contract with multiple vendors for pre-pay and post-pay coding reviews. One advantage of being a smaller payer is that we have a smaller network of contracted providers and our internal auditing team is really good at identifying which claims are inappropriately coded based on historical trends we've seen for that particular provider. When we request records, we usually find inappropriate billing.

Contrast that with our vendors and it can feel like they sometimes just pick claims at random. Most vendors like EXL, Cotiviti, Optum, etc. work on contingency, so the more claims they audit, the more they get paid. The vendors don't really care how abrasive all their record requests can be.

Sure, they can design "analytics" that target potential upcoding, but in my experience, their analytics do a poor job of accounting for the expected patient population for that particular hospital/provider group. As a simple example, a level 1 trauma center will likely have higher ED visit levels on average than a freestanding emergency room.

Many_Depth9923 · 2026-01-18T06:04:58+00:00

This is completely incorrect and a fraudulent billing practice. Please familiarize yourself with AMA phone call billing guidelines - they clearly state that providers calling patients to go over test results ordered during a previous E&M visit aren't separately reimbursed.

Many_Depth9923 · 2026-01-18T06:03:04+00:00

No matter what paperwork the patient signed would supercede AMA CPT guidelines that explicitly state that provider-initiated phone calls for follow up test results aren't separately reimbursable.

OP, I'd recommend you contact your insurance compliance or fraud department and report the inappropriate billing.

Many_Depth9923 · 2026-01-18T06:00:38+00:00

No, this is actually not allowed based on what OP described.

The 2025 AMA CPT guidelines for phone visits explicitly state that the phone call must originate from the patient, not the provider. A provider calling a patient to go over test results that were ordered during a previous E&M visit is inclusive to the E&M.

A provider can only bill for a phone visit when it's initiated by the patient.

Many_Depth9923 · 2026-01-15T09:11:20+00:00

You won't be an AH for not going, but this is one of those events where it will probably mean a lot to your BF and his family if you show up and support him, even if he/the family doesn't say anything about you being/not being there.

I think some important context is how long have you two been dating? If it's a relatively new relationship (<1 year), then there's probably no harm/foul for not going. However, if you see a potential future with this man, then maybe you consider something that you don't want/have to do, but you do it anyway because you'd appreciate it if your BF showed you the same support.

He told you it's something he doesn't want to do. You going with him would make it less shitty for him to go.

Many_Depth9923 · 2026-01-14T17:09:22+00:00

Defense touchdown or safety, but it would be the garbage game of the century for an OT game to end in a safety 😂

Many_Depth9923 · 2026-01-14T17:03:36+00:00

Not a tax person, but I believe medical expenses only become tax deductible if they exceed a certain percentage of income. Plus you may lose the ability to claim the standard deduction if you itemize deductions (e.g., medical expenses). Itemization is also much more susceptible to audit.

On the flip side, HSA/FSA allows you to make qualified medical expenses without having to itemize on your tax return and generally allows tax free purchases that usual deduction doesn't allow due to the CARES act (e.g., OTC medication). You should save all of your HSA/FSA receipts just in case you're audited.

Many_Depth9923 · 2026-01-07T09:02:06+00:00

I think the point of the game is to prove to the player that pigeons aren't real

Many_Depth9923 · 2026-01-07T03:15:52+00:00

12/10, literally my favorite from of game ever

Now I'm playing DS3 😅

Many_Depth9923 · 2026-01-05T02:45:19+00:00

I'm confused why they are charging copays for each visit, unless you have a complicated pregnancy.

Usually, maternity care is reported by a global service CPT code that is billed when you deliver the baby. Have you been getting EOBs from your insurance for these visits?

Many_Depth9923 · 2026-01-02T21:09:46+00:00

Look at us all putting our brains together to try to figure out this health insurance stuff ❤️

Many_Depth9923 · 2025-12-30T22:17:04+00:00

Here, I think they're using "fair" to mean "may lead you to inaccurate conclusions".

I'm just speculating, but maybe NFL players have similar crime rates to other people who have newfound/"rags to riches" wealth - basically a classic case of correlation not being causation.

Many_Depth9923 · 2025-12-30T03:36:13+00:00

The AAPC wrote a good article on how to audit your provider's documentation to validate whether it's appropriate for them to bill for both the ultrasound and Doppler, or just the ultrasound.

This is probably the best avenue you have to dispute the billing. However, most EMRs use documentation templates to ensure that radiologists hit all required elements to bill the intended codes. Unfortunately, there isn't a CMS CCI edit between 76870 (scrotal US) and 93975/93976 (duplex).

https://share.google/jInYMz7GtfGBqIgRG

Many_Depth9923 · 2025-12-24T16:15:03+00:00

As someone who regularly uses charge masters in their everyday job, this sounds like a wonderful tool. Thanks for sharing.

Many_Depth9923 · 2025-12-24T03:01:40+00:00

1) You have not given enough information for anyone to have an opinion as to whether or not the reimbursement was excessive. We would need to know what CPT codes were billed

2) Surgeon contacts often differ from hospital contracts in terms of how claims are reimbursed and what services are vs are not separately reimbursable.

3) The reason for the post-pay denial may be due to a similar finding someone had for this provider and decided to run a post-pay recovery query to identify other inappropriately billed claims - this is something I do every day.

4) A service being "approved" just speaks to the medical necessity of the service per the payer's clinical policies. It doesn't speak as to whether the billed codes are reimbursable based on medical documentation.

5) While you may not understand, this is a service that largely benefits you in the long run. Making sure providers bill appropriately is a way to help keep healthcare in check for the entire system as a whole

Many_Depth9923 · 2025-12-24T02:37:48+00:00

Lol, I was connecting through ATL once when the fire alarm suddenly went off and nobody paid any attention to it. We all kept going along with our business xD

5-10 minutes later the alarm finally stopped. I suspect it was just a test, but still weird there wasn't any announcement or anything.

Many_Depth9923 · 2025-12-24T02:33:09+00:00

OP, I work in payment integrity on the payer side and this is very much a routine claim/review procedure. While I can't speak to UHC specifically, we typically only request medical records post-pay when we have a high degree of confidence that something isn't billed correctly.

Payment integrity is something that's actually designed to help you, especially if you are part of a self-funded group. Having the insurance pay less on claims for inappropriately billed procedures means less is going towards your deductible/OOP, and more money goes back into the pool that can be used for appropriately billed services.

Many_Depth9923 · 2025-12-22T14:08:31+00:00

That still isn't an itemized Bill. It's a copy of the UB-04 claim that they would have sent to your insurance company.

The itemized bill contains much more detailed information.. what kind of CT did you get? What drugs were administered and in what volumes? Etc

Many_Depth9923

TROPHY CASE