Case Study: Challenging Modifier Misuse Allegations with Horizon New Jersey
Client Impact: $300,000 in Paid Claims | Resolution Time: 30 DaysKey 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 […]
Case Study: Holding Golden Rule Accountable in Florida and Indiana
Total Client Impact: Over $620,000 in Recovered Revenue | Two States, Two Systemic WinsKey Outcomes: Misrepresentation Corrected in FL | DOI Intervention in IN Florida: Correcting Misrepresentation and Securing Full-Year Coverage The ChallengeIn 2013, families affiliated with the Florida Institute of Technology (FIT) purchased Golden Rule insurance plans based on broker assurances that ABA therapy […]
Case Study: Correcting Systemwide Denials for CPT 0373T with Indiana Medicaid
Client Impact: $500,000 in Paid Claims | Resolution Time: 4 MonthsIndustry Impact: Statewide System Fix for All ABA Medicaid Providers The ChallengeIn Indiana, ABA providers faced a critical billing disruption when CPT 0373T—a Category III code essential for adaptive behavior treatment with protocol modification—was excluded from Indiana Medicaid’s provider-to-procedure code linkage system. This oversight resulted […]
Case Study: Bridging the Gap Between Blue Cross Blue Shield of Texas and Blue Cross Blue Shield of South Carolina
Client Impact: $350,000 in Paid Claims | Resolution Time: 1 year and 35 Days The Challenge A provider partnered with Missing Piece ABA Billing experienced claim denials from Blue Cross Blue Shield of Texas (BCBS TX) for CPT 97153, an essential ABA therapy code. While BCBS TX requires specific modifiers on these claims, all submissions […]