Medical Billing Forum

Billing => Billing => Topic started by: goldeneyes711@msn.com on July 30, 2016, 05:21:00 PM

Title: need help with hysteroscopy removal iud insurance denied
Post by: goldeneyes711@msn.com on July 30, 2016, 05:21:00 PM
Hello, I am new to this forum.

A patient came in to our ob/gyn office with an iud, which was inserted a few years ago by another provider to control her menorraghia. The iud was retained, so a hysteroscopy removal of the iud with a diagnosis of menorraghia and complication of iud needed to be done (cpt 58562). Her insurance has denied the claim saying patient is not covered for contraception, but the iud is not being used for contraception. Has any one ever had this billing problem?

Any help you can provide will be highly appreciated.
Title: Re: need help with hysteroscopy removal iud insurance denied
Post by: kristin on July 30, 2016, 06:46:18 PM
I don't bill OB/GYN, but wouldn't the next logical step here be to appeal the denial, by sending in the treatment note/op report along with a letter stating that the IUD was not there for contraceptive purposes, but for menorraghia?

Title: Re: need help with hysteroscopy removal iud insurance denied
Post by: Michele on August 01, 2016, 07:28:26 AM
I don't bill OB/GYN, but wouldn't the next logical step here be to appeal the denial, by sending in the treatment note/op report along with a letter stating that the IUD was not there for contraceptive purposes, but for menorraghia?



That's exactly what I would advise.  It is probably standard for them to deny any procedures that can be contraception.  If it is for something other than contraception an appeal needs to be filed.  Make sure you include all supporting documentation including the letter explaining that you are appealing because it is not related to contraception.
Title: Re: need help with hysteroscopy removal iud insurance denied
Post by: goldeneyes711@msn.com on August 01, 2016, 07:39:47 PM
I don't bill OB/GYN, but wouldn't the next logical step here be to appeal the denial, by sending in the treatment note/op report along with a letter stating that the IUD was not there for contraceptive purposes, but for menorraghia?

Kristin thanks for your response. However, I have already sent all documentation with a letter explaining the medical necessity for the use of the iud on this patient, and the insurance co. still denied appeal saying pt needs to address medical necessity with her employer.

Once again, thanks

I don't bill OB/GYN, but wouldn't the next logical step here be to appeal the denial, by sending in the treatment note/op report along with a letter stating that the IUD was not there for contraceptive purposes, but for menorraghia?



That's exactly what I would advise.  It is probably standard for them to deny any procedures that can be contraception.  If it is for something other than contraception an appeal needs to be filed.  Make sure you include all supporting documentation including the letter explaining that you are appealing because it is not related to contraception.

Michelle thanks for your response. I have sent all documentation with an appeal letter already, but insurance denied claim again, because apparently the insurance company can not accept the fact that 58562 needed to be done to remove a retained iud being used to control the pt's bleeding.

Once again many thanks.
Title: Re: need help with hysteroscopy removal iud insurance denied
Post by: kristin on August 01, 2016, 08:06:32 PM
Take it to the next level of appeal. And the next, if necessary. Don't give up.
Title: Re: need help with hysteroscopy removal iud insurance denied
Post by: Michele on August 02, 2016, 07:19:50 AM
Take it to the next level of appeal. And the next, if necessary. Don't give up.

Ditto.   I wouldn't accept that answer.  I would also ask the patient to inquire with their employer as well, since ultimately she will be responsible if they don't pay.
Title: Re: need help with hysteroscopy removal iud insurance denied
Post by: PMRNC on August 02, 2016, 09:08:48 AM
Quote
I have already sent all documentation with a letter explaining the medical necessity for the use of the iud on this patient, and the insurance co. still denied appeal saying pt needs to address medical necessity with her employer.

If this is an employer group health plan you want to do an appeal using ERISA. Have the patient sign a valid Authorization for representation with you and have them contact the employer. It sounds like self-administered plan which gives the employer a bit more lead-way in getting things paid so I would get the patient involved. Also since this is ERISA you want to have the patient give you a copy of their SPB.. I HAVE seen plans that exclude contraceptive DEVICES.. PERIOD.

Title: Re: need help with hysteroscopy removal iud insurance denied
Post by: goldeneyes711@msn.com on August 03, 2016, 12:33:02 PM
Quote
I have already sent all documentation with a letter explaining the medical necessity for the use of the iud on this patient, and the insurance co. still denied appeal saying pt needs to address medical necessity with her employer.

If this is an employer group health plan you want to do an appeal using ERISA. Have the patient sign a valid Authorization for representation with you and have them contact the employer. It sounds like self-administered plan which gives the employer a bit more lead-way in getting things paid so I would get the patient involved. Also since this is ERISA you want to have the patient give you a copy of their SPB.. I HAVE seen plans that exclude contraceptive DEVICES.. PERIOD.

Many thanks PMRNC, for your great response. Yes, apparently the patient has a self-administered plan. Therefore, I have asked the patient already to get in touch with the employer and resolve the medical  necessity issue with them as advised by the insurance co. SPB-summary of policy benefits?? In all the years I have been doing medical billing this will be the first time doing an ERISA appeal. What have your experience been with them if any?

Again many thanks.
Title: Re: need help with hysteroscopy removal iud insurance denied
Post by: PMRNC on August 03, 2016, 12:56:29 PM
Quote
In all the years I have been doing medical billing this will be the first time doing an ERISA appeal. What have your experience been with them if any?

Bet you it's not you just don't realize it. More than 85% of the claims you touch are ERISA (group sponsored plans) ERISA is federal therefore they are overseen by the DOL. Any group health plan with the exception of state/govt or church are ERISA which is why I say you have touched many more ERISA claims than you have NON ERISA claims. :)

The SPB is the Summary Plan Benefit. If you choose to help the patient it's a good idea to get a copy of their SPB. At the same time they should sign what is called an ERISA Authorized Representative Form. This is a special form that the patient signs to allow you to represent them in the appeal. With ERISA the claims are not the providers claim, they are the patient's claim. Same thing if a carrier comes back and wants to recoup money on claims they paid to the provider, they cannot because they should go to the patient for the money back, NOT the doctor. Imagine how much money doctors have given back because they or their billing staff didn't understand ERISA? A LOT Of money!!!

Don Self has a great book on ERISA and appeals.. It should be on every billers must have list. www.donself.com