Re: Insurance issue: Pre-authorized codes then considered incidental after prosthesis is delivered

Re: Insurance issue: Pre-authorized codes then considered incidental after prosthesis is delivered

Marty Mandelbaum

6/14/2018

On Mon, Jun 4, 2018 at 11:06 AM, Marty Mandelbaum < <Email Address Redacted> >
wrote:

> Empire Blue Cross Blue shield pre-authorized the following L7400 and
> L7403 and then denies payment saying these codes are always considered
> incidental codes. I realize that insurance companies always say
> authorization is not a guarantee of payment, but that should relate to the
> policyholder loosing coverage or other reason not for the insurance company
> to get out of paying for something they did indeed authorize.
> These codes are add-ons for socket laminations that are allowed under our
> current L-code billing system.
> Has anyone else had a similar incident and how did you resolve this?
> Thanks
> Marty Mandelbaum CPO
>


​ Responses:​

1 This will not stop until the government steps in and attacks insurance
companies. Patients won’t get involved because they got the device. The
insurance companies just have the right to do whatever they want. You
just have to keep fighting them and fighting them with strong
documentation. The government does need to mandate that if you require an
authorization and the insurance company approved the device as medically
necessary, it guarantees payment and timely. I don’t know what is up with
insurance companies, but it is getting horrible in so many ways. Insurance
companies that were considered better insurers have became the worst. They
just delay as long as possible and have you fight as long as you are
willing to the point that you give up bc of all of the wasted time and
money to try to get paid. I really hope something changes bc all we want
to do is provide quality patient care and help restore lives and get paid
for what we do. The push for us to all be able to provide quality care is
for us to have our group get this to the government for help. I’m afraid
that we are under attack from all.

I had a back pain stimulator of over 60k placed in my back and approved and
paid to doctors. It failed after two weeks due to improper tightening of
the leads in my back to the anchors and most would think, the medical group
would have to do the surgery to correct as it was nothing I did to cause
this and it only last 2.5 weeks before the leads pulled completely out of
the epidural space on their wallet. But guess what, the surgeons and
medical group get it approved for revision surgery and will get paid
another 17k to do it over. This really upsets me bc we fight every day
now with many insurers to get paid but those same insurers approve and pay
the doctors without a fuss at least in my situation. I realize the doctors
have struggles as well but nothing like our field.

2 I haven't experienced this from Anthem in particular, but a lot of
insurance companies are referring to the NUCC Edit system and it is
creating all kinds of havoc, particularly in UE prostheses. Personally I
feel like they're misusing and not understanding the coding edits (not that
I'm any kind of pro at it) because there are few policies about UE
prostheses, but there's something with the socket add-on codes that are
creating these edits. If someone presents a solution, please share it! I'm
experiencing the same issue with our state Medicaid program saying the
socket code itself is causing the error. As if the the NUCC edits aren't
allowing any additions at all to an UE socket. I still have yet to hear a
real explanation for their reasoning, just a general check the NUCC for
coding edits.


3 The big picture that we're seeing is Medicare's resources are being
systematically diverted away form beneficiaries and providers and towards
an ever enlarging federal bureaucracy. Under present circumstances, I don't
think there is anything that can be done to reverse or to negatively
influence this trend. The clinic I work for has routinely stopped accepting
assignment. It is possible that the option to selectively refuse assignment
will also be terminated by CMS. consequently, our goal is to operate
profitably on less than the co-payment amount which is not going to be an
easy thing to do.

4 Did you also obtain a procedure specific benefits/verification before
providing the service? If so, that will help you. I would appeal this
based upon the grounds that a) you obtained auth, b) there is no clinical
or incidental/vs. non-incidental standard in upper extremity prosthetics
since CMS has no LCD for upper extremity and c) I just reviewed the Empire
Medical Policies and did not see any indication that they consider these
incidental. I would also argue that in my appeal. I will also state that
I was reading it from my cell phone and could have overlooked but I would
encourage you to go read them and use the lack of written position to your
argument.

5 Yes, an auth is not a guarantee of payment but did you get a code
specific verification or benefits check? Where you call benefits and
provide them all of the procedure codes and they confirm if they are
covered or not and what benefits apply? If you did this, and were
specifically told that x procedure code is covered, you can argue equitable
estoppel which basically says that payers are responsible for providing
accurate benefit information when specific inquiries are made. This is
different than an auth. An authorization is just a review that says a
patient should medically qualify for something under the plan and that
review has determined it okay to provide. An approval is beneficial to
your appeal but I would say even more beneficial is the benefit inquiry
when you verify the exact coverage of each procedure code.

Thanks for all your input, we are still fighting this.
Marty Mandelbaum CPO