If a carrier downcodes a claim and the provider maintains that the reported services were medically necessary, the medical office specialist should:
A) send a bill to the patient for the remaining balance.
B) write off the remaining balance.
C) file an appeal with the insurance carrier.
D) send a complaint to the state insurance commissioner.

Question

Quizplus · Accepted Answer

Filing an appeal with the insurance carrier is the best option in this situation. The provider should gather any additional documentation or information that supports the medical necessity of the services and submit an appeal to the carrier for reconsideration. Sending a bill to the patient for the remaining balance or writing off the balance would not be appropriate if the services were medically necessary and were provided in accordance with accepted standards of care. Sending a complaint to the state insurance commissioner would be premature and not likely to result in a resolution without first exhausting the appeals process with the carrier.

If a Carrier Downcodes a Claim and the Provider Maintains