Superbill’s Guide to Out-of-Network Coding
Insurers are always looking for new ways of moving services out-of-network to reduce costs. Regardless of what kind of provider you are, there’s a good chance you’ve had to work through the tedious process of coding services for out-of-network insurance reimbursement. If you’re a therapist or specialist working exclusively with superbills, you know this all too well.
Not only is there more work for providers filing out-of-network claims, there’s also a higher probability of rejection. Because there’s no contract between an out-of-network provider and an insurer, a bill for an out-of-network service often causes the entire claim to be flagged. Insurers pay closer attention to out-of-network claims, scrutinizing them for even the smallest errors. In order to get your client the maximum allowed reimbursement, your coding has to be precise.
Take note of these tips to ensure your next superbill or out-of-network claim is in tip-top shape.
Make sure the claim is complete and accurate.
It probably goes without saying, but you might be surprised by how many claims are rejected due to naming errors. Double-check that the patient’s name and address are the same on every document. Insurance companies will take any opportunity they get to reject an out-of-network claim.
Code Concisely and Correctly
Insurers assume there is an exact code for every service rendered. While the reality may be more complicated than that, there is a best code or set of codes for every service. Don’t under-code by leaving out appropriate ICD-10 or CPT codes, and don’t over-code by adding extra ICD-10 or CPT codes. While it may seem helpful to fluff the claim with extra codes for a greater reimbursement, you may actually get the claim flagged, which could result in rejection of other parts of the claim that otherwise would have qualified for reimbursement.
Describe the Service When Unspecified
If you can’t find an exact code for the service rendered and have to use an unspecified CPT code, include a description of the service. Describing the service increases its chances of being reimbursed.
If You’re Unsure, Review the Policy
Pretty much every insurer lists their policies online. You can usually confirm whether or not the service rendered will be reimbursed by reviewing the insurer’s website. Yes, this can be tiresome, but these are insurance companies we’re talking about…
Review the Patient’s EOB
It’s tempting after filing a few claims and getting into a groove to assume every patient’s policy with the same insurance payer is identical, but in truth, patients’ policies may differ even under the same umbrella plan. Taking an extra look at each patient’s Explanation of Benefits might inform you to use a different code given the circumstances.
Refile, Refile, and Refile Again
A rejection is not the end of the health insurance claims process. In many cases, it’s just the beginning. Every insurance payer has an appeals process, and many reject out-of-network claims on sight on the first go around, in the hopes that you simply give up. At Superbill, we often have to refile the same claims several times to get patients the maximum allowed reimbursement. We hate seeing insurers hold onto money that belongs in patients’ pockets, and we know you do too. Hopefully these tips help.
If you’re looking to go deeper, the American Academy of Professional Coders has a more comprehensive list of coding best practices, as well as a complete guide to CPT codes.