Was Your Claim Underpaid? Check Before Appealing

Noridian’s appeal team has been receiving hundreds of appeals requesting additional reimbursement amounts. The Medicare fee schedule amounts do not reflect all appropriate reductions that apply in a variety of situations.

Nurse Practitioners (NP), Physicians Assistants (PA), Licensed Clinical Social Workers (LCSW), and other non-physician type providers are reimbursed less than physicians when billed under their own Provider Transaction Access Number (PTAN).

Another reduction is providers who select to be Medicare Non-Participating (Non-PAR) vs Medicare Participating (PAR). Non-PAR Providers receive a 5 percent reduction. Participation means you agree to accept claims assignment for all Medicare-covered services to your patients. Par providers agree to accept Medicare allowed amounts as payment in full along with any deductible and coinsurance amounts. Non-PAR providers agree to not charge the patient more than the limiting charge which represents 115 percent of the Medicare Physician Fee Schedule amount. You must not "exceed the limiting charge" or appeal amounts.

Incorrect place of service (POS) can also affect the payment amounts you receive. Facility POS such as outpatient hospital (22), or inpatient hospital (21) are paid at a lower rate than an office (11). Make sure you are using the correct POS for the service location you are billing for. The payment amounts for a facility on the fee schedule is identified with a # in the column (note) next to the CPT Code.

Reviewing your remittance advice, fee schedules and the payment methods for the provider type your billing for is the best way to determine if there is a valid reason for an appeal.


Last Updated Apr 03 , 2024