Medical billing - Black box editing

A second common form of bundling is through “black box” coding edits. “Black box” edits refer to claims editing software that health insurers
purchase and then customize to automatically ignore certain modifiers or to group certain CPT codes together in a manner contrary to CPT instructions. The term black box comes from the fact that health insurers consider theseedits proprietary and keep them secret. The physician typically is reimbursed for just one procedure and receives no reimbursement for the second procedure.
Black box edits are very problematic because of the secretive nature of the edits. For example, some third-party vendors will customize surgical
“packages” for health insurers’ billing purposes. What services or procedures are included in the package are often unknown and may not be consistent with CPT. Moreover, there are any number of idiosyncratic edits that are difficult
to even decipher from an explanation of benefit (EOB) form. Sometimes physicians can figure out certain edits after getting numerous denials
or lower reimbursement for the same service or procedure, but this is still difficult.

It is particularly troubling that commercial health insurers insist on using secret “black box” edits, in light of the Centers for Medicare and Medicaid Services’ (CMS) decision to eliminate black box edits in the Medicare program and make all coding edits public.While CMS’s approach to the issue of coding edits is not perfect, this new policy acknowledges and respects that physicians
have a basic right to know coding policies and procedures before claims submission.

CMS also has solicited the AMA and national medical specialty societies for input into matters relating to coding edits through the Correct Coding Policy Committee. Through this process, the national medical specialty societies have
reviewed and submitted comments on tens of thousands of proposed edits to CMS. CMS has reconsidered some proposed edits as part of this
process. Commercial health insurers, in contrast, have shown little interest in eliminating “black box” edits or in seeking outside physician inputas to the clinical justification for these arbitrary edits.


Anonymous said...

I hadn't been very familiar with "black box" edits in medical insurance billing before reading this. Very helpful article.

naresh said...

Hello to every one,

This site is very usefull to who r working in helath care organization,while using this site i was learn so much billing info.


Medical Billing Popular Articles