Recently (insurance company) – one of the 3 CMO managed Medicaid plans in (State) have started to reverse payments on previous claims from 2006 & 2007. These claims involve additional E&M charges that were documented and billed on the dates of service for problems managed or identified in prenatal patients. For example, one set of charge-backs involve four E&M claims billed over a nine-month prenatal period for a prenatal patient who was found to be positive for GC & Chlamydia and required treatment and counseling for the initial diagnosis and follow-up test of cure after the initial treatment. In addition, this patient developed glycosuria which necessitated evaluation of and management of gestational diabetes. From weeks 19-28, the patient was seen every two weeks, and weekly thereafter for follow-up and management of her elevated blood sugars, weight control, and fetal growth monitoring, in an attempt to prevent the need for a C-section as a delivery method due to a macrosomic infant. These additional visits were billed as E&M visits with additional charges for follow-up ultrasounds and non-stress tests. This billing of the E&M for the additional visits follows CPT guidelines for complicated OB patients who require care out of the scope of the routine “normal” global services.

The insurance company’s justification for reversing these charges is that the E&M charges were billed with obstetrical diagnosis codes, therefore these services are part of the routine global obstetrical care codes. They did not notify the physician practice that they were reviewing these claims. The practice found out when they received EOB’s showing these additional charges as charge-backs. The insurance company’s position is that non-payment of recently billed services is justified because the practice owed a refund for these E&M OB visits.

The practice’s position is that appropriate billing requires these E&M’s to be billed with appropriate diagnosis codes from the 600 series E&M’s. Most patients over the course of nine months of care will come in at least once for a problem that is either a complication of the pregnancy or a problem unrelated to the pregnancy which requires additional care.

The practice has already contacted their state family practice association for help, but to date has received little assistance.