My daughter went to the ER recently. Insurance is denying it since it wasn’t an “emergency”. Funny, they billed us as a 99284 (99281 is the minimum severity, 99285 is the max severity). But they didn’t give us any discount. I am wondering if the GoA might have a claim from these embezzeling FLICKS! Humana is the insurer
Tax id is 39-0806374
Does anyone have a discount that they can PM me and the charges/alloweds for the 99281-99285’s?
This site didn’t have Emergency listed, thus useless. My data never had a claim there (Virginia - so yeah, not surprised)
I will fill it out - they offered me a small cash paying discount. I am adding these (the #'s below) to the form to see what happens. I think it explains what I want done, but if you think I am missing something please let me know (maybe in a PM?). Trying not to give out to much HIPAA nor contracting amounts:
#16 Checking boxes 2, 3, 4 (Ex T- is looking to see if Mayo is in netowrk with HUM) #18: We were notified that the diagnosis used wasn’t an “emergent” situation. However, the CPT codes charged were 99284 for the non-facility and ##### (IOU - I didn’t see the facility claim just yet) for the facility. These are high severity codes indicating that this encounter may, in fact, be “emergent” Either (1) Have the Mayo facility (Tax id # ##-#######) and non-facility (39-0806374) rebill the claim as a non-emergent diagnosis or (2) apply Humana’s in network discount / fee schedule on the entire claim and cover it (subject to Deductibles, coinsurance and copays)
The Doc (Non-Facility) bill is $600, the Facility is $1,575 (sort of an average charge for both the 99284’s). I don’t have the diag - however I won’t publish that on the interwebs.
She is fine - was uncomfortable for a few days and needed urgent care. But the facility is located REALLY close to the school - almost a little abusive tytt.
Have you appealed the claim yet with Humana? I don’t have any idea what symptoms she presented with, but the diagnosis codes might not reflect the symptoms correctly. For example, I once reviewed a $300K claim with a diagnosis of nosebleed. It turns out that the person did have a nosebleed but was a hemophiliac. However, that diagnosis code did not show on any of the claims. My guess is that this claim was auto-adjudicated and that no person looked at it yet. (I don’t work for Humana so I can’t really speak to their process) On appeal, they will take a closer look and probably get the medical records which would indicate the presenting symptoms. With a 99284, the symptoms should have been pretty severe and I would generally expect the claim would be excepted as an emergency claim after review of the medical records. I wouldn’t be surprised if Mayo up charged the claims though in which case you have strong evidence to get Mayo to correct the claim with the proper code.
We (Ex, MiniT-2) called the hospital, they told us to call the insurance company, who told us to call the provider, and back and fourth. Still in the “filling out the requests/paperwork” in the order that we need to. Why we have to do anything but say “MiniT-2 discussed XYZ with the provider” is beyond me).
I told both provider (Mayo) and insurance company ((Humana! and I used to work for you - shame on you!) to either (1) reduce the severity to correctly go with the diagnosis, (2) add the correct diagnosis, head injury, for the severity or (3) make us a cash paying customer with a 40% discount off the current charge.
Filling out the forms for Humana, this was my “request”
We were notified that T-2’s Emergency Room visit was denied because the diagnosis was for “vomiting, diarrhea, and nausea” and the ER visit CPT coding, for both the ER facility and ER attending physician, was for a CPT code of 99284 – ER emergent level 4. Humana’s claim adjudication process, and our discussion with Emilia @ Humana’s customer service on 8/16/2022, says that this diagnosis, stated above, is not an emergent situation. I was surprised the Doctor notes didn’t say that she blacked out (so - no head trauma). These are high severity CPT codes indicating that this encounter is in fact “emergent”. We’d kindly request either (1) Have the Mayo facility (Visit #1110429854) and non-facility (attending physician) (Visit #1109998033) rebill the claim as a non-emergent (ex: ER CPT 99282 or 99283) visit or (2) Apply additional diagnosis codes (head trauma, fainting) that were talked about to signify the “Emergent” situation as documented or (3) apply Humana’s in network discount / fee schedule on the entire claim and cover it (subject to Deductibles, coinsurance and copays).