A provider contacted the GIRS InContact Reimbursement Hotline® when he received a lower than expected reimbursement from a private payer on a client’s biologic. The caller asked for assistance on coverage and payment. The payment was inadequate for the specified billing codes.
The counselor forwarded the provider’s inquiry to the Payer Advocacy Compass® (PAC) team and a conference with the provider was arranged to initiate a plan of action. The goal was for the PAC team to request the payer to review and adjust the fee schedule for the biologic.
GIRS was able to find the Medicare fee schedule information for the same codes. The PAC team sent a letter with other relevant pricing information for the medical technology to the payer medical director and followed up with their pricing staff educating them about the pricing of the code.
The Medicare fee schedule and a letter of medical necessity (LMN) was also sent to the provider to forward to the private payer for his appeal.
The provider was grateful for the time and effort expended by the hotline on his behalf on the matter. The payer agreed to review and update their fee schedule. This is an example of how GIRS InContact Reimbursement Hotline and PAC team work together providing integrated reimbursement solutions to support our clients.
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