When Payers Underpay You: What is Your Recourse?

While researching a problem, I came across an unknown remark code on a very popular payers remittance notice (EOB).  So, I looked online and found out that this payer was subtracting monies from our payments incorrectly in not just one area, but another area, as well.  It was less than two dollars per visit but when you have 30,000 plus visits per year, this can certainly add up quickly.

Here is what went down:

I was looking for the sequestration subtractions for our 2017 claims and was not seeing any CO235's for any of the 2017 dates of service.  They stopped appearing on the EOBs on Dec. 30, 2016.  I poked around online trying to see if there was a reason that we were not getting that deduction on the MPPR (multiple procedure payment reduction) on our 2017 claims, but did not uncover anything.  So, I looked back at the EOB and then found several N699 codes.  This code means 'Payment adjusted based on the Physician Quality Reporting System (PQRS) Incentive Program.'  Back in December we noticed that we were being charged for not meeting specific criteria through our EHR system.  We monitor this area very closely and contacted our EHR company who filed an informal appeal on our behalf (and several more for their other clients) stating this large, popular payer made a big mistake within their system.  The large, popular payer acknowledged their mistake and let our EHR know the issue would be remedied as soon as possible.  Yet, they continue to take subtractions of our payments while they worked to "remedy the situation".  So, we decided to call the large, popular payer and they claimed it would take up to six months to pay us back!  This is the same company that if you don't pay them back an overpayment within 30 days, they subtract their overpayment on a current payment to you.  That doesn't seem right to me.

While we were working on this problem, I noticed for one of our newest staff members that this large, popular payer was taking subtractions for not following reporting guidelines in 2015 for PQRS.  This staff member's NPI (the one and only) was created on 9-15-2016.  There is no possible way this staff member could have reported in 2015.  So, this is another error this payer made. They have sent an urgent request to stop deducting from our payments, and will make restitution for repayment.

Great, we get paid back when it's convenient for them.  We should be happy they acknowledged their error and said, "Okay, you win.  We will pay you back."  But what about all of those providers out there who don't even look at these EOBs and have no idea what these remark codes mean?  Wouldn't this be considered payer fraud?  What about all of the administrative time we've spent and will continue to be spending on the future identifying all of their payment errors?

Regardless of what you call it, you are most likely being robbed of your payments. Take a moment to review your EOBs.  Be sure you are looking at ALL payers to know if you are being paid the amount your contract states, and that any other deductions must be identified and true and valid.  If not, get on the phone today and get those remedied.