Spravato clinics across the country are experiencing a widespread underpayment issue from major insurance carriers. Many providers are unknowingly losing significant revenue due to downcoding, rejected CPT codes, and payer system errors.
This article breaks down the root causes behind Spravato claim underpayments and outlines practical steps Esketamine clinics can take to identify errors, recover lost revenue, and protect their reimbursement.
Why Spravato Claims Are Being Underpaid
Insurance companies are systematically downcoding and rejecting Spravato related evaluation and management services. The most common issues include:
- Downcoding CPT code 99215
- Rejection of add-on code 99417
- Failure to recognize time-based billing
- Incorrect automated EOB processing
Spravato treatments require extended observation periods, typically two hours or more. However, many payer systems do not properly recognize that these claims are time-based services. As a result, insurers process them as standard office visits rather than prolonged care encounters.
Major payers affected include:
- Ambetter
- Blue Cross Blue Shield
- Cigna
- Humana
- Medica
- Prime Health
If your clinic auto-posts EOBs without manual review, these errors are likely going unnoticed.
Automated EOB Posting and Its Impact on Spravato Reimbursement
Automated EOB posting can lead to significant revenue loss when payer errors occur. Since insurer systems are misreading Spravato claims, auto posting prevents staff from catching:
- Underpayments
- Incorrect contractual adjustments
- Invalid remark codes
- Rejected add-on CPT codes
Manual auditing is critical to ensure accurate reimbursement for Spravato services.
How to Identify Underpayments in Spravato Billing
To recognize underpaid claims, clinics should take the following steps:
- Review Insurance Contracts and Fee Schedules: Keep a current copy of your payer contracts and contracted rates. Knowing exactly how much you should be paid is essential for identifying discrepancies.
- Cross Check EOBs Against Contracted Fees: Compare each EOB to your fee schedule. Pay special attention to:
- Allowed amounts
- Patient responsibility
- Remark and adjustment codes. These remark codes often explain why a claim was downcoded or denied.
- Maintain Accurate Payer Contact Information: Once you reach the correct billing or claims department at a payer, document the contact details. This saves time for future follow-ups, which are often necessary for Spravato claims.
The Importance of Time Documentation for Spravato
Accurate time documentation is essential for successful appeals. Always record:
- Observation start time
- Observation end time
- Total treatment duration
This information supports time-based coding and is often the deciding factor in appeal approvals.
How to File Successful Spravato Appeals
Due to systemic payer errors, many Spravato claims require multiple appeals before correct payment is issued. A strong appeal should include:
- Date of service
- CPT codes billed
- Contracted reimbursement amounts
- Explanation of underpayment or denial
Supporting Documentation to Include
- Spravato Prior authorization approval
- Copy of the original claim
- Medical records showing start and end times
- Brief explanation of Spravato and medical necessity
Highlighting the time documentation within the medical record helps reviewers quickly identify the basis for time-based billing.
Submitting Appeals the Right Way
Whenever possible, submit appeals through the insurance portal. If portal submission is unavailable, fax is the next best option, followed by mailed appeals. Always keep organized records of:
- Submission dates
- Confirmation numbers
- Representative names
- Reference numbers
Tracking this information is essential when appeals require multiple follow-ups.
Watch the Timely Filing Limit
Each payer has a Timely Filing Limit for appeals. Missing this deadline can permanently prevent reimbursement, even if the claim was underpaid due to payer error. Clinics should track appeal deadlines closely.
Persistence is key. Many Spravato appeals are denied once or twice before being approved and paid correctly.
Final Thoughts
Spravato billing & coding is complex, time sensitive, and often impacted by payer system errors that lead to underpayments and repeated appeals. Managing audits, downcoded CPT codes, and follow-ups can quickly overwhelm your internal teams. FC Billing simplifies this process. As a full-cycle Spravato billing company, we provide specialized Spravato billing services, helping Spravato clinics recover accurate reimbursement while freeing providers to focus on patient care.
