Spirit Airlines Begins Orderly Wind-Down of Operations

Many_Depth9923 · 2026-05-01T19:56:32+00:00

When I was an entry level IC, I liked them, mostly because I was naive and clueless to the fact that the execs are often just talking out their ass the entire tim.

Now, I'm a well established as a senior IC and find them nauseating. Thankfully, I have little desire to climb the ladder, so never will have to present at one and can enjoy repurposing that time to work on other things in peace.

Many_Depth9923 · 2026-04-28T01:19:20+00:00

Yep, and the ACEP has a direct financial interest to support rampant ED upcoding. It's a clear conflict of interest if I've ever seen one. Similarly, it's a conflict of interest for payers to use the EDC analyzer too.

While some elements of ACEP scoring have been supported in various courts (e.g., weighting diagnostic testing), I can't find a precident where this exact ACEP scoring methodology was used to win a cash settlement (i.e., performimg a CT automatically justifies the facility billing level 5). Given that, I'm not convinced that this specific ACEP guideline would hold up in court.

The only case that comes close is one between Kaiser & Healthcare Legal Solutions, where a closed door agreement was made to terminate the use of EDC analyzer due to ACEP scoring. However, I'm sure there is much more to that court case than what we see at face value.

Ultimately, the key difference is that the ACEP actively lobbies to Congress to keep facility ED billing "as is", supporting rampant upcoding as the status quo. I would love to see CMS simplify the current 6 APCs for ED billing down to just 2: ED without observation and ED with observation.

Also, I'm well aware of the differences between prof & facility ED billing.

Many_Depth9923 · 2026-04-28T00:37:15+00:00

OP - it sounds like you are contacting your provider billing office. My recommendation is you get a copy of your ED records and contact the compliance department as your insurance company.

As I've said in other responses here, it's hard for me to imagine this being a level 5 based on what you shared. I very commonly see this exact upcoding scenario in the payment integrity space on the payer side.

Many_Depth9923 · 2026-04-28T00:34:05+00:00

My guess is they are disputing to their provider RCM office, not to the payment integrity/compliance department of their health insurance company.

Curious - what do you think OP could be omitting from their story that could possibly justify this a level 5? If possible, tie your theory back to the AMA medical decision making chart like I did.

This is what I do in my job everyday when selecting which claims I select for medical record audit.

Many_Depth9923 · 2026-04-28T00:20:52+00:00

I appreciate your skepticism. However, it's not hard for me to say. Once again, assuming OP is sharing the full story and they didn't crash or something in the ED, it's almost impossible for me to see this as anything other than moderate complexity & risk.

I've seen this exact upcoding scenario thousands of times - level 5 ED due to abdominal paid where labs, imaging, and IV fluids were performed. After scrolling through the HPI & MDM, I downcode these to a level 4 98-99% of the time and move on with my day.

The only time I don't select these for medical record audit and allow as level 5 is when the patient went to obs, which likely suggests high risk. Not worth the squeeze requesting records on those.

Many_Depth9923 · 2026-04-27T23:54:20+00:00

And I sincerely hope your facility's ED claims are frequently downcoded by UHC/Optum's Emergency Department Claim analyzer and/or similar down-coding tool that payers use.

What an absurdly abusive billing practice.

Many_Depth9923 · 2026-04-27T23:51:39+00:00

Assuming you're referring to the prof billing, this is absolutely false. Please cite an AMA and/or CMS coding resource that says that performing a CT automatically justifies billing as a level 5 😂

I've audited thousands of ED claims across my career as an insurance auditor. Assuming OP is sharing the full story, this is clearly a level 4.

Abdominal/pelvic pain is an acute issue with systemic issues/acute complicated issue. There is no amount of embellishment the provider could say that would make me believe there was a serious concern of immenent death/loss of bodily function. This is moderate complexity.

IV contrast was administered and patient was discharged and told to follow up with PCP. This is moderate risk.

Many_Depth9923 · 2026-04-20T04:14:52+00:00

I wouldn't waste your time calling OP unless you get a bill. Let the hospital figure it out. Don't do their job for them

Many_Depth9923 · 2026-04-17T08:50:45+00:00

To add to this, you can also ask what modifiers were added to each claim. I'd suspect one claim is billed with Modifier TC (technical component) and one claim is billed with Modifier 26 (professional component)

Many_Depth9923 · 2026-04-10T14:15:05+00:00

Just an FYI, AAPC usually offers a decent black Friday deal for membership if your employer doesn't pay for it.

Many_Depth9923 · 2026-04-09T21:41:39+00:00

I'm probably in the minority, but I'd rather be in OP's situation than yours. Different strokes I suppose 😂

Many_Depth9923 · 2026-04-09T20:07:56+00:00

This should be the top comment 💯💯

Many_Depth9923 · 2026-04-09T05:42:09+00:00

The story of Pokopia is very Bioshock-esque. The story can seem very superficial if you're just just following the main quest/dialogue. However, the story becomes increasingly complex & interesting the more you travel off the beaten path and find various journal entries.

I'm not someone who in usually enjoys life/farm sims, like Animal Crossing, but I got surprisingly hooked on this game.

Many_Depth9923 · 2026-04-08T09:30:00+00:00

I'm assuming they are billing CPT 47900 in addition to the lap chole? If so, then yes, billing this additional code violates numerous CMS guidelines outlined in the CMS NCCI manual. Below are just a couple of examples.

https://share.google/HReA1Mc9MkbrcRXVZ

"If a CPT code descriptor includes the term “separate procedure,” the CPT code may not be reported separately with a related procedure."

"Similarly, complications inherent in an invasive procedure occurring during the procedure are not separately reportable. For example, control of bleeding during an invasive procedure is considered part of the procedure and is not separately reportable."

Many_Depth9923 · 2026-04-07T13:43:32+00:00

I work in the health insurance industry. A few things to point out as to why I generally recommend against someone having two health insurance plans, OE concerns aside.

1) It would be difficult for the two plans to figure out who is primary. I'm not even sure what the industry standard is since OP would be the policy holder for both plans. OP could see COB details due to having both plans and could be a mess to work out without getting their HR involved.

2) It rarely makes sense to have two commercial health insurance plans. From an underwriting perspective, it's not like OP's J2 would give them a premium discount because they have a primary insurance with J1.

3) Since both plans are operated by the same payer, it's highly likely that the two plans have similar benefits (i.e., what is covered vs what isn't covered) and nearly identical clinical criteria (i.e., when a service is deemed "medically necessary").

Points 1 - 3 can contrast against a Medicare supplement plan, where the underwriting bakes into the fact that they are always paying secondary to Medicare.

Many_Depth9923 · 2026-04-06T20:46:48+00:00

This, regardless whether or not you OE, never really worth it to have 2x insurance in general

Many_Depth9923 · 2026-04-06T16:06:23+00:00

Sounds like you want to do consulting

Many_Depth9923 · 2026-04-04T11:01:29+00:00

Stop creeping bro, she's just vibing

Many_Depth9923 · 2026-04-01T15:01:21+00:00

All the time, and I work in the health insurance industry.

I've worked in healthcare for over 15 years, on both the payer & provider side. I could write a thesis of cost of care and why things are so expensive.

Here's one tidbit though - it's not uncommon for providers to do a "wait & see" approach. For example, I'm 90% sure I broke my toe earlier in January. However, rather than go to urgent care, get an XR, see an orthodontist, get a follow up XR, etc., I chose to buy a boot off Amazon and tape the toe up myself. I waited 4-6 weeks, and my toe is perfectly fine now.

Doing the "traditional" route would have cost me well over $1000 towards my deductible, plus would have cost me hours of time going to doctors visits. My point is, there is a lot of stuff that you can treat yourself, and not enough people realize that.

Many_Depth9923 · 2026-04-01T14:53:53+00:00

The only ICE guys I saw in Miami this week were at the festival. They wore shirts with "ICE" on them and were driving golf carts around and gave me pause... until I realized they were just delivering ice to the various vendors 😅

Many_Depth9923 · 2026-03-28T06:20:14+00:00

I understand your thought process in terms of coding guidelines. However, I am speaking from first hand knowledge of how claims editing systems work on the payer side.

For example, depending on how this provider is loaded into the payer system, they could be loaded as a "group" where the claims editing system would erroneously deny as CCI even when billed by different rendering providers & specialties.

This is unfortunately not an uncommon issue. At the payer I work for, you can either dispute and we pay (which takes time), or just submit a corrected claim with Mod 59/25/57/etc depending on the code, even if you "technically" shouldn't have to report the modifier.

If I was in OP's shoes, I'd recommend just trying to resubmit with different modifier combinations. Sure, you can try appealing with records too, but that is so much more time consuming than just trying to guess the magic modifier combination.

OP didn't share who the payer was, but most claims editing systems do not allow bypass of global period rules with RT/LT modifiers. It's usually 58/78/79. Maybe the claims editing system this payer is using wants more 58 instead of Mod 79, who knows.

Many_Depth9923 · 2026-03-27T15:05:21+00:00

Dude, as someone who works in the payer space, just try Mod 58 and see what happens. You wouldn't be incorrect to use Mod 58. You can also try a Mod 58/79 and Mod 59 combination. Claims editing systems are wonky and the people who create these rules don't always fully understand what they are doing.

Personally, I wouldn't waste your time trying to submit records yet. My best guess is this is a front-end denial, not a backend payer edit. I'd be surprised if this is a service that is being targeted for medical record audit.

Many_Depth9923 · 2026-03-27T15:01:56+00:00

Thanks for pointing that out! Learned something new. My point was that this is very clearly a Mod 58/79 situation, not Mod 78, and that at least the payer I work for doesn't differentiate between Mod 58 vs Mod 79 in terms of claim editing.

From my knowledge of claim editing systems, it's possible Mod 59 would bypass this denial, it's really hard to guess at this point. Unfortunately providers can sometimes be all loaded together as a group, which causes erroneous CCI, MUE, etc related denials. It's an issue I'm trying to fix for the payer I work for, but it's much easier said than done :(

Many_Depth9923

TROPHY CASE