As healthcare providers, our priority is delivering medically necessary care that improves our patients’ lives. However, we often face an uphill battle when it comes to ensuring fair reimbursement for those services and in 2024 this battle seemed to turn into a war.

Recently, I have encountered several denials from United Healthcare regarding physical therapy services provided to patients. The reason cited? “A minimum of 15 minutes was not documented” for codes 97110 and 97112, despite the claims being meticulously aligned with both AMA and CMS billing guidelines for time-based services.

Let’s be honest—this kind of denial is likely the result of a computer algorithm or an untrained representative making decisions without fully understanding the complexities of billing guidelines. Unfortunately, this scenario is all too common in our field.

Another Example:

In a similar case involving a workers’ compensation payer, a claim was denied because the patient’s recorded time in and out of the clinic did not align with the billable treatment time. This decision completely ignored the fact that clinic time includes both billable and non-billable activities, such as check-in and patient preparation. Only billable time was submitted, as per industry standards, yet the payer unjustly denied the claim. This would be justified if the billable time exceeded the time in and out, but in this case, it was less by 2 min because the patient was present for 2 min of non-billable time.

Why does this matter?

1️. Denials like these undermine the financial sustainability of clinics and the ability of therapists to provide quality care.

2️. They create unnecessary administrative burdens, forcing therapists to defend their expertise and documentation practices instead of focusing on patient care.

3️. They set a dangerous precedent—if insurers deviate from standard guidelines without transparency or accountability, it leaves providers and patients vulnerable to unjust practices.

What can we do?

It’s time for us as therapists to take a stand. We must appeal these denials, demand clarity from insurers, and advocate for fair processes. We can’t allow unqualified decision-makers or unchecked algorithms to dictate the value of the care we provide.

A Call to Action:

If you’ve faced similar denials, don’t let them slide. Appeal, advocate, and raise awareness. The more we stand together and challenge these practices, the stronger our collective voice becomes. Let’s protect the integrity of our profession and ensure our patients receive the care they deserve without compromise.

Have you had similar experiences? Let’s discuss ways we can collectively address these issues!

Below is a sample template appeal letter /comments for these situations

Sample Template Appeal Letter:

Date: United Healthcare Appeals Department

Re: Appeal for Claim Adjustment Patient:

Dear Appeals Department,

I am writing to formally appeal against the denial of payment for physical therapy services provided to (patient name). The claims in question was denied on the grounds that “a minimum of 15 minutes was not documented for codes 97110 and 97112.”

Upon reviewing United Healthcare’s published guidelines, it is evident that these denials are both unwarranted and inconsistent with standard billing practices. Therefore, we respectfully request an adjustment to appropriately reimburse these medically necessary services.

On DOS , a total of 41 minutes of timed codes were billed as follows:

· 14 minutes for 97110

· 17 minutes for 97530

· 10 minutes for 97112

On each day 3 units were billed which is in alignment with either AMA or CMS billing guidelines for time-based services, which represent the standard of practice across the industry. If United Healthcare relies on alternative billing guidelines that deviate from these standards, we request clarification on where and how such guidelines are communicated to providers. Abruptly deviating from these established norms without notification or transparency is unjust and directly impacts the providers delivering care and the patients receiving it.

Requested Action:

We request that United Healthcare:

· Reevaluate the denial of claims for the appropriate units billed, ensuring compliance with AMA or CMS billing guidelines.

· Provide written education of your billing practice guidelines with reasoning for why they deviate from the industry standard.

Thank you for your prompt attention to this matter. If additional documentation or further clarification is required, please do not hesitate to contact us.