Client Impact: $300,000 in Paid Claims | Resolution Time: 30 Days
Key Outcome: Pre-Payment Review Lifted | Claims Paid Within 15 Days
The Challenge
In 2019, the American Medical Association updated the CPT codes for ABA services, including guidance that speech therapy code 92507 should not be billed in conjunction with 97153 or 97155. However, when ABA and speech services were rendered on the same date—clearly as separate and distinct sessions—Missing Piece ABA Billing applied modifier 59 to indicate this distinction, in accordance with Horizon New Jersey’s published definition.
Despite correct coding and clear documentation, Horizon flagged the provider for “overuse” of modifier 59 and placed them under a burdensome pre-payment review process. This review disrupted claims flow and jeopardized timely reimbursement for necessary services.
The Advocacy
Missing Piece ABA Billing immediately pushed back on behalf of our provider. We escalated the issue and insisted on a face-to-face meeting with Horizon’s medical and claims review teams. During the meeting, we presented:
- Strong clinical documentation demonstrating the separation of services
- A thorough review of Horizon’s own policy language defining modifier 59
- A clear rationale for the claims’ accuracy and the appropriateness of reimbursement
The Outcome
Horizon acknowledged the validity of our position and removed the provider from pre-payment review. Claims began processing normally again, and all outstanding claims were paid within 15 days. In total, $300,000 in delayed payments were recovered.
The Bigger Picture
This resolution not only restored claims flow for our client—it reaffirmed the importance of accurate coding advocacy and payer accountability. It also sent a message to payors that correct use of modifiers, when backed by documentation and policy alignment, should not trigger punitive action.
Conclusion
At Missing Piece ABA Billing, we go beyond billing—we defend our providers’ right to timely reimbursement, even in the face of payer audits and reviews. Our hands-on approach ensures that clinical integrity is matched with financial accuracy.