Medical Billing Coding - part of a procedure not covered, cpt, codes
medical billing and coding forum

BC Advantage Magazine


Billing-Coding.com

(FORUM HOME)

General Medical Billing Forum

New Topic  |  Search

Thread Topic: part of a procedure not covered
Topic Originator: anil
Post Date August 16, 2006 @ 6:54 PM
part of a procedure not covered


anil
August 16, 2006 @ 6:54 PM Reply  |  Email Friend   |  |Print  |  Top

33225 is a code for coronary sinus lead placement which is always part of biventricular pacemaker placement. We are being denied payment for this code by blue cross blue shield saying that auto company policies do not cover this code but rest of the procedure is covered. Being in detroit we see lot of auto company patients. This seems ridiculous. Any ideas how to solve this issue ?

Leah
August 16, 2006 @ 6:57 PM Reply  |  Email Friend   |  |Print  |  Top

Bill the patient.  Non-covered it non-covered and as such is billable to the patient.

anil
August 16, 2006 @ 7:08 PM Reply  |  Email Friend   |  |Print  |  Top

Thanks for the reply. Billing the patient does not solve the problem. You lose patients and the referring docs that way. Is there another way like using a miscellaneous code etc. Is it legal for insurance to not cover a part of surgical procedure that is otherwise essential to patient care?

peg
August 16, 2006 @ 10:59 PM Reply  |  Email Friend   |  |Print  |  Top

You could submit appeal letters stating the medical necessity of the procedure in conjuction with the other procedure, and explaining that the patient will be responsible for payment if not allowed. My company has over a 90% success rate in wining claims appeals of this nature.

Leah
August 17, 2006 @ 8:00 PM Reply  |  Email Friend   |  |Print  |  Top

"Not covered" is not the same as "not medically necessary".  Your appeal would be fine and dandy and likely quite successful if the denial reason was because the procedure was deemd not medically necessary for some reason or other.  But "Not a covered service" is not an appealable denial.

peg
August 18, 2006 @ 12:10 AM Reply  |  Email Friend   |  |Print  |  Top

I disagree. Auto carriers pay our appeals once we make it clear their insured will receive the bill. We have not run into problems with this.

Steve Verno
August 23, 2006 @ 11:19 AM Reply  |  Email Friend   |  |Print  |  Top

What you are dealing with is a contract between the patient and their insurance company.  

The insurance company is saying that the service you are providing is not a benefit that the member is entitled to receive.  Hence the term, non-covered services.

The patient is responsible for all non-covered services.  It is YOUR decision not to bill the patient, but it is the patient's contractual requirement to pay.  Your not wanting to bill the patient could be in violation of several federal laws.

1)  By not billing the patient, you could be in violation of the Anti-kickback statute.  You are telling the OIG that by not making the patient pay for a service that was received, you are taking a kickback and this induces the patient to come back and see you.  The patient says, "This is great, I get to go to see Dr. A for my medical condition and he won't make me pay for the medical care."  That's a kickback.

(2)  By not billing the patient. you could be in violation of the Stark Act.  By giving away medical care for free, you are allowing the patient the ability to refer other patients with that same medical condition with the same insurance to come to see you because they won't be billed for the non-covered service.

You cannot force an insurance company to pay for medical care that is NOT a benefit.  Again, this is a contractual issue between the patient and their insurance company.  The insurance company, when providing the patient with benefits, gives the patient a benefit manual or a summary plan description.  This document clearly outlines what services are covered and what services are excluded.  You know what Medicare allows and you know what Medicaid allows.  If the patient comes to you and asks for a service that Medicare says is not covered, are you going to demand Medicare pay for the non-covered service or are you going to bill the Medicare patient for the services that are not covered?  Actually, you will tell the Medicare patient that the service is not covered.  If you feel that Medicare may not pay for the service, such as with certain treatments when only a specified number of treatments is allowed, then you must counsel the patient and have them sign an ABN form.  This allows the patient to make an informed and freedom of choice decision to continue with the care, knowing they have to pay, or to decline the care.  Well, you have to do the same thing with your non-Medicare patients.  YOU HAVE TO TALK TO YOUR PATIENTS ABOUT THEIR FINANCIAL REQUIREMENTS!  The caps are for emphasis, not yelling.  I've been to at least 10 doctors due to a car accident.  NONE of them even spoke with me about my financial requirements.  NONE!  We talk to our patients about the medical care they are receiving, yet, we are mute with speaking to them about money.  Why?  Why are we so afraid of this?  

When a patient makes an appointment with you, you should be asking them to bring a copy of their benefit manual or summary plan description with them.  You should sit down with them and go over the manual to see if the medical care is a benefit.  If the service is not a benefit, you have a mandatory requirement to tell the patient this and to allow the patient the freedom of choice decision to continue with the care, knowing they have to pay, or to decline the care.  Even if the doctor is contracted, look at the contract to see if you can bill the patient for non-covered services.  You may find that the provider has a contractual obligation to speak with the patient, inform the patient that the services are not covered and have the patient agree to be billed for the non-covered services.  

Ladies and Gentlemen, the problems we face are the problems we cause ourselves.  We assume the claim we send is our claim, when in fact it is the patient's claim.  Look at any benefit manual.  A claim is a request by a member to have a health benefit paid.  When an insurance company pays or denies the benefit, they send a document called an "Explanation of Benefit"  Not Explanation of the Provider's Claim"  The insurance company, based on a legal and binding contract with the member, pays only for benefits that the member is entitled to receive.  If the medical care is excluded, or non-covered, the insurance company denies the claim for benefits because the medical care is not a benefit.  If the service is a benefit, then the amount to be paid is also based on the contract with the member.  The exception is when the doctor contracts and accepts a negotiated amount.  So, if the insurance company says it pays usual and customary, we cannot force them to pay more than the contract allows.  If an appeal is required, it is the patient that has the appeal rights, not us, but we take on the appeals process ourselves without the patient's permission. The exception is when the provider is contracted.  How many times do we appeal when our doctor is not contracted?  Happens all the time.  We were trained to appeal, but do we have the right to appeal when the provider is not contracted?  The appeals rights rest with the patient.  The appeals process is a legal proceeding because we are

Steve Verno
August 23, 2006 @ 11:19 AM Reply  |  Email Friend   |  |Print  |  Top

What you are dealing with is a contract between the patient and their insurance company.  

The insurance company is saying that the service you are providing is not a benefit that the member is entitled to receive.  Hence the term, non-covered services.

The patient is responsible for all non-covered services.  It is YOUR decision not to bill the patient, but it is the patient's contractual requirement to pay.  Your not wanting to bill the patient could be in violation of several federal laws.

1)  By not billing the patient, you could be in violation of the Anti-kickback statute.  You are telling the OIG that by not making the patient pay for a service that was received, you are taking a kickback and this induces the patient to come back and see you.  The patient says, "This is great, I get to go to see Dr. A for my medical condition and he won't make me pay for the medical care."  That's a kickback.

(2)  By not billing the patient. you could be in violation of the Stark Act.  By giving away medical care for free, you are allowing the patient the ability to refer other patients with that same medical condition with the same insurance to come to see you because they won't be billed for the non-covered service.

You cannot force an insurance company to pay for medical care that is NOT a benefit.  Again, this is a contractual issue between the patient and their insurance company.  The insurance company, when providing the patient with benefits, gives the patient a benefit manual or a summary plan description.  This document clearly outlines what services are covered and what services are excluded.  You know what Medicare allows and you know what Medicaid allows.  If the patient comes to you and asks for a service that Medicare says is not covered, are you going to demand Medicare pay for the non-covered service or are you going to bill the Medicare patient for the services that are not covered?  Actually, you will tell the Medicare patient that the service is not covered.  If you feel that Medicare may not pay for the service, such as with certain treatments when only a specified number of treatments is allowed, then you must counsel the patient and have them sign an ABN form.  This allows the patient to make an informed and freedom of choice decision to continue with the care, knowing they have to pay, or to decline the care.  Well, you have to do the same thing with your non-Medicare patients.  YOU HAVE TO TALK TO YOUR PATIENTS ABOUT THEIR FINANCIAL REQUIREMENTS!  The caps are for emphasis, not yelling.  I've been to at least 10 doctors due to a car accident.  NONE of them even spoke with me about my financial requirements.  NONE!  We talk to our patients about the medical care they are receiving, yet, we are mute with speaking to them about money.  Why?  Why are we so afraid of this?  

When a patient makes an appointment with you, you should be asking them to bring a copy of their benefit manual or summary plan description with them.  You should sit down with them and go over the manual to see if the medical care is a benefit.  If the service is not a benefit, you have a mandatory requirement to tell the patient this and to allow the patient the freedom of choice decision to continue with the care, knowing they have to pay, or to decline the care.  Even if the doctor is contracted, look at the contract to see if you can bill the patient for non-covered services.  You may find that the provider has a contractual obligation to speak with the patient, inform the patient that the services are not covered and have the patient agree to be billed for the non-covered services.  

Ladies and Gentlemen, the problems we face are the problems we cause ourselves.  We assume the claim we send is our claim, when in fact it is the patient's claim.  Look at any benefit manual.  A claim is a request by a member to have a health benefit paid.  When an insurance company pays or denies the benefit, they send a document called an "Explanation of Benefit"  Not Explanation of the Provider's Claim"  The insurance company, based on a legal and binding contract with the member, pays only for benefits that the member is entitled to receive.  If the medical care is excluded, or non-covered, the insurance company denies the claim for benefits because the medical care is not a benefit.  If the service is a benefit, then the amount to be paid is also based on the contract with the member.  The exception is when the doctor contracts and accepts a negotiated amount.  So, if the insurance company says it pays usual and customary, we cannot force them to pay more than the contract allows.  If an appeal is required, it is the patient that has the appeal rights, not us, but we take on the appeals process ourselves without the patient's permission. The exception is when the provider is contracted.  How many times do we appeal when our doctor is not contracted?  Happens all the time.  We were trained to appeal, but do we have the right to appeal when the provider is not contracted?  The appeals rights rest with the patient.  The appeals process is a legal proceeding because we are

Steve Verno
August 23, 2006 @ 11:32 AM Reply  |  Email Friend   |  |Print  |  Top

This is the only thing I hate, when you hit the wrong key and it posts your posting and you can't go back and correct.

Getting back.

An appeal is a legal proceeding based on a contract between the patient and their insurance company. The appeals process is also protected by State and Federal Law.  We aren't lawyers.  If we appeal on our own and we fail and then turn it over to the patient, the timelines for the patient to appeal can be lost, thereby denying the patient their appeal rights.  If we fail in our appeal, we could open ourselves to a lawsuit from the patient.  You see, the benefit manual or Summary Plan Description outlines the appeals process, in detail.  Without looking at these documents and appealing without permission and appealing to see if what we are appealing is correct, we are doomed to fail.

I say all of this because it all comes together.  This is the 21st Century and we cannot do our jobs like we did back in the 1990s.  Things have changed.  We need to work smartly when we do our jobs.  We need to ensure that we communicate with the patient, not just with their medical care.  We need to ensure that we know what medical care the patient is entitled to receive that their insurance will pay and what medical care the patient is required to pay.  We cannot be afraid of billing the patient for fear of losing a patient.  We MUST bill the patient when required.  Yes, you will lose a patient when you bill them and never talked to them and informed them they would get a bill.  An informed patient returns to see the provider.  An informed patient knows what medical care is payable by their insurance and what they have to pay themselves.  An informed patient doesn't get angry when they are told they have to pay and you show them why.  The patients that get angry and leave, even when told, are the "Wolves" and the wolf is a patient that will never pay a medical bill.  A wolf gives incorrect insurance information, a wolf becomes intimidating and threatening when told about their financial requirements and when confronted with their lies about false insurance information as well as their bad address.  You don't need a wolf and you can make the wolf extinct by following a good compliance plan, a published financial plan, and speaking to them.

Leah
August 24, 2006 @ 2:37 AM Reply  |  Email Friend   |  |Print  |  Top

peg, auto insurance is NOT health insurance and it plays by different rules.  Auto insurers are required to pay for "damages", and any medically necessary procedure to treat an injury sustained in an automobile accident is "damages".  Health insurers are not tort-related therefore they are only required by law to pay for what they explain in advance they will pay for.  So your argument is a non-sequiter.

Dana
September 6, 2006 @ 11:00 PM Reply  |  Email Friend   |  |Print  |  Top

Lets face it the pt has no idea what their plan covers and the insurance company is in the business to make money....Let the pt know that you are going to do an appeal on their behalf (yes steve it is legal to appeal) but they need to assist you by contacting member services and assist with the appeal.  Lets see, have you read their SPD and does it specifically exclude that from their plan?  I can bet it doesn't and a appeal would get it paid.  A billing service or a provider that lays down to a denial any denial is weak and in the wrong business.....lets see, helping people, hmmm, what a concept.....just droping a bill in the mail to someone who probably doesn't have the money to pay......a cop-out



Copyright © 2008 Billing-Coding Inc