Author Topic: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!  (Read 978 times)

PippiT

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Good morning! Hoping I can get assistance with what my next steps should be.

We have a patient we have done the same procedures on 8 times since November.

Before we ever did the procedure, I called multiple times to check to see if authorization was needed. I was told the same thing every time which was all codes are valid and billable no precert required. Two of the codes are covered if medically necessary, notes may be requested to pay claims.

At first, denials were coming in asking for ops notes. They were submitted.

They are Outpatient SX claims. The facility claims are the biggest issue. They are being denied as not covered. but then below that it says, "we have found the service requested is not medically necessary in your case". It then goes on to say "based on current information, coverage cannot be approved because there is insufficient scientific evidence to demonstrate the  safety and/or effectiveness of Amnioband for any indication including wound care....Falls under experimental/investigational/unproven, which the customers plan does not cover."

I need advice on what I can do next. (Appeal, have the doctor discuss with a physician reviewer, send claims to a service like Collect RX). This is a first and I'm confused as to how so many CSRs including the preauth department that these codes were covered and do not require precert and then be denied as not covered. Can someone please help me understand? Thank you in advance and if more information is needed, I will do my best.




Michele

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Re: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!
« Reply #1 on: February 08, 2017, 12:58:42 PM »
I would suggest filing an appeal showing the documentation from the phone calls.  Hopefully you were given reference numbers for the calls.  However, the phone calls usually will say covered, no auth needed, "based on medical necessity" so it sounds like they are stating that the procedures were not medically necessary.  Therefore, you need to appeal that portion as well.  Basically the provider needs to state why they disagree with that (not medically necessary) and why.  Include any supporting documentation backing the provider up.

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PippiT

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Re: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!
« Reply #2 on: February 08, 2017, 02:07:33 PM »
Thank you for your response. That was what I thought I may have to do and I have reference numbers for every single call. I have given them all the documentation from the past two years. Any idea what additional information we could submit?

kristin

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Re: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!
« Reply #3 on: February 08, 2017, 06:12:16 PM »
I deal with a lot of wound care billing involving various types of grafts. First, here is a link to the company that makes the graft, and billing procedures depending on type of provider/facility:

http://mtfwoundcare.org/www/reimbursement/

Next, there should be a graft representative/billing reimbursement specialist for MTF Wound Care(who makes AmnioBand) that you can contact for advice/help. You need to enlist them to help you fight these denials, that is part of what they are there for. They should have also run benefits/coverage on the patient first, because generally if the graft doesn't get paid, and the provider did everything right, the graft company is on the hook for the cost of the grafts, as opposed to the provider. So it is in their best interest to make sure the graft will be covered first.

Finally, it could turn out to be that this patient's insurance will not cover this particular graft brand, for whatever reason(experimental, investigational, etc). They may cover a different graft brand, or they simply may not cover these types of grafts at all. Or, it could be they don't feel it is medically necessary if not enough conservative treatment was rendered first to the patient. Often, insurances will want documentation of at least four weeks(sometimes more) of conservative treatment before grafts are used.


PippiT

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Re: No Preauth Required, CPTs valid & Billable - Claims Being Denied-Help!
« Reply #4 on: February 15, 2017, 09:45:09 AM »
I deal with a lot of wound care billing involving various types of grafts. First, here is a link to the company that makes the graft, and billing procedures depending on type of provider/facility:

http://mtfwoundcare.org/www/reimbursement/

Next, there should be a graft representative/billing reimbursement specialist for MTF Wound Care(who makes AmnioBand) that you can contact for advice/help. You need to enlist them to help you fight these denials, that is part of what they are there for. They should have also run benefits/coverage on the patient first, because generally if the graft doesn't get paid, and the provider did everything right, the graft company is on the hook for the cost of the grafts, as opposed to the provider. So it is in their best interest to make sure the graft will be covered first.

Finally, it could turn out to be that this patient's insurance will not cover this particular graft brand, for whatever reason(experimental, investigational, etc). They may cover a different graft brand, or they simply may not cover these types of grafts at all. Or, it could be they don't feel it is medically necessary if not enough conservative treatment was rendered first to the patient. Often, insurances will want documentation of at least four weeks(sometimes more) of conservative treatment before grafts are used.

Thank you for this information! Our rep is getting me in touch with the 3rd party group that helps getting these paid.

PippiT

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I am still fighting this.

Long story short, Multiplan reached out to us on 3 of the out of network claims and we settled them, the problem is they never paid us and then Cigna started sending denials that the procedure was experimental/investigational.

A company supervisor reached out to me and was all "hey this is a mess! I'm going to help you." she sent me the medical policy and in it, it clearly states it is not covered. We never would have done the procedures. I did everything right, the CSRs gave us wrong information. I tried to get predeterminations and they wouldn't saying that the codes were covered, etc. I also tried to get a preauth but because his plan didn't require it they wouldn't give me one.Oh, and the supervisor after this never returned my calls or emails after this initial contact.

Per the provider I filed a complaint with the state insurance commissioner and it was referred to the AG's office. I worked with our investigator and she sent the appeal to the company last week. Is there anything I need to do? I am still getting denials and I don't know if I should be appealing directly with the company still, or wait until the case has been investigated?

I hope that makes sense. I am at my wit's end.

Michele

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If the case is being investigated by the insurance commissioner/ AG then I would wait for a response.

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PippiT

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Okay, that is what I thought but I didn't want to chance anything. Thank you!