Oxford – Are you being paid properly for 99201-99215?

Once denied, are you getting the runaround when trying to get them reprocessed? Don’t write them off—read on!

We attended an Oxford/Triad seminar. During this seminar it was explained by an Oxford Medical Director that Oxford should be reimbursing exams (CPT codes 99201—99205 for new patient exams and 99211—99215 for re-exams) provided they were billed correctly. He stated that it was Oxford’s policy that exams were a separate reimbursable procedure for policies NOT managed by Triad. He further clarified that if a policy was managed by Triad, exams would be covered as long as the service was authorized by the Triad reviewer. Providers expressed concerns that they were not being reimbursed for these services, but the Oxford Medical Director was confident that Oxford was working to correct this issue.

It is now years later, and these CPT codes continue to be denied. Don’t stand for it! Whether it is a policy NOT managed by Triad or a policy managed by Triad (and approval has been obtained) these CPT codes are routinely denied. In a poll conducted over the last few months, we found that most providers and their offices are writing them off instead of fighting for proper payment. We feel this is part of the problem! 

In the past, our procedure has been to call Oxford’s customer service and request the claim be re-processed. We were told these codes denied per Oxford’s processing guidelines and Reps could not override the system. We would then request a supervisor and be transferred to their ‘Executive Services’ department. 

At that level we are either told they would have the exam reprocessed (which often doesn’t happen), or they would offer to do a verbal appeal on the provider’s behalf, or instruct us to send in a written appeal. From that—the result was another denial!

We became tired of this game and started to send regular letters to the Oxford CEO about this issue. In this letter, we would reference the meeting and outline our complaint that this issue was still not rectified. We would then attach a list of all the patients that had exam CPTs code denied. I will tell you that this CEO and his staff were very helpful and most exams were re-processed and paid. Although we appreciated the reliability of this Oxford

CEO and his office staff in this regard, we continued to urge them to correct their systems so that this would not continue to be an issue in the future. Since then the project has been turned over to the office of the Senior Vice President.

As of late, we have been working directly with an Oxford representative in this office on correcting Oxford’s processing system to allow these CPT codes to process when initially billed —as long as they are billed correctly and within the timeframe per CCI edits.

To all our readers—don’t write those exams off! I know it involves extra work to get them paid by Oxford—but there is a light at the end of the tunnel!!

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