Help, They Wont Pay For The Exam!
Written by Andrea Howard   
Wednesday, January 17, 2018 01:23 PM

By Kelli Moore, MCS, P-I 
The Collection Coach

I recently received a call from a distraught office manager who explained that a major insurer was consistently denying the Evaluation and Management codes, otherwise known as “exam” codes, when performed on the same day as a Chiropractic Manipulative Treatment (CMT). She explained that these denials created a significant loss of revenue to the practice and that her efforts of calling the insurer to remedy, rendered little results. I gave her three steps to take to help eliminate the problem, here they are.

First, make sure the mistake was not yours. Double-check the claims to be sure that the proper modifier was added. Since the CMT has similar definition elements to the Evaluation and Management code, they will be denied when billed on the same day if billed by the same provider. To avoid the denial, the modifier 25, should be appended to the Evaluation and Management code. This tells the insurer that the Evaluation and Management was a different, separately identifiable, service from the CMT. If this was missing from the claims, add it and resubmit. But, what if the modifier was properly added, and the claim was still denied?

The next step, would be to call the insurer to get them to reprocess the claim. This is usually a short conversation. Simply explain that a clean claim was submitted with the proper modifier, according to the American Medical Association (AMA), who publishes the CPT codes. The customer service agent should be able to look at the claim, see that the proper modifier is in fact there, and send it back for reprocessing. This will typically work, but occasionally, it doesn’t. They insurance representative may ask that the records be submitted, what then?

It is time to “escalate” the call. That means, they must now transfer the call to a supervisor. Take the position that clean claims were submitted with the proper modifier, and there should be no reason to submit records. Communicate that  you are attempting to save everyone the time and effort of a manual records review. Use these three reasoning points with the supervisor: 1) since clean claims were submitted, they are now obligated to pay the claims according to the Prompt Pay law, 2) if claims are not paid promptly, the clinic may be entitled to receive interest, penalties and possibly damages and attorney fees, and 3) this may be a violation that could expose the  insurance company to fines from the Texas Department of Insurance for Unfair Claims Settlement practices, Deceptive Trade Practices and discrimination against a Doctor of Chiropractic, if it is discovered that the insurance company is deliberately stalling or refusing to pay claims based on the service being provided by a chiropractor.

Using this reasoning with he supervisor should convince them to reprocess the claims. If there is more than one date of service that needs attention, keep the supervisor on the line until all of them are addressed. Get all your claims handled at once. It may take a while, but it will be worth it.

I will be discussing this and many more practice building subjects to help clinics collect more money while reducing the risk of audit, in my upcoming class, Advanced Training for Office Managers and Experienced CAs, on April 6-8, at the Texas Sports and Chiropractic Conference in Pasadena, TX. For more information call the TCA at 512-477-9292 or visit their website to register at