Private insurers won' t pay on spinal codes:4 steps to take to encourage privates to see the light

Why This Topic Matters

Bundling disputes can affect payment consistency across payers and create recurring denial management work for practices. The article highlights how coding references, compliance guidance, and payer escalation may be used when private insurer handling differs from Medicare or published guidance.

Article Sections

1. Private insurers won’t pay on spinal codes

   Introduces a payment dispute involving spinal surgery-related claims and private payer denials. The section frames the issue as a reimbursement and policy inconsistency problem.

2. Book them

   Discusses the use of coding reference materials and payer appeals correspondence in support of separate payment. It describes an initial attempt to document the basis for the claim position.

3. Show them CCI edits

   Covers checking claims edit resources and communicating the results to payers. It focuses on how edit references were used as part of the denial challenge.

4. Cite OIG guidance

   Addresses compliance guidance and escalation correspondence involving an oversight agency. It also notes concerns about how payers classify the issue.

5. Try the medical director in person

   Describes a final escalation step involving direct discussion with a medical reviewer. The section closes by emphasizing persistence in the appeal process.