What to Do When You're Denied
Some payers deny compensation for proper patient care and also declare that you can't bill the patient.
BY GIL WEBER, M.B.A., Davie, Fla.
Some third-party payers tell practices that CPT 92135, Scanning Computerized Ophthalmic Diagnostic Imaging
(SCODI), is a noncovered service and is therefore not reimbursable. Some even declare that practices can't bill patients. If you've experienced such a compensation denial -- or if you code for CPT 92135 -- then read on. I'll tell you how to improve your chances for reimbursement when insurers don't pay.
That was then
Years ago, if an insurance plan didn't cover a service or a procedure, then a practice could simply tell the patient that his insurance didn't cover the service or procedure and that he was financially responsible for the charges. The patient would agree to pay and that was that.
In recent years, managed care plans have asked practices to get the patient to sign a financial responsibility acknowledgement form before providing noncovered services. And until recently, that simple protocol adjustment was sufficient in most instances.
Practices almost always knew what services or procedures the insurance plans wouldn't cover, and these noncovered items were what you'd reasonably expect. For example, elective/cosmetic services and procedures were a patient's responsibility, as were "upgrades" such as designer eyeglass frames. The noncovered services were similar from plan to plan so you almost always knew up front what was what.
This is now
But now some payers routinely deny coverage for certain services and procedures that reasonably seem to warrant coverage. It's frustrating when the eyecare profession adopts new technologies as the standards of patient care, but payers ignore them.
CPT 92135 has become particularly troublesome for practices across the country, in large part because Aetna, a major insurance player, has promulgated a national policy that classifies SCODI as "experimental" and therefore not reimbursable.
But to make matters worse, on top of denying financial responsibility for the care, some plans (including Aetna) have gotten between the practice and the patient by putting up impediments to charging the patient for these noncovered services.
So how can you avoid situations where a payer's rules would cause you to work for free? Finding the answer to this problem is complicated because today, what an insurance plan covers isn't always clear.
We know what Medicare covers. For example, when we use the OCT
(Zeiss), GDx (Laser Diagnostic Technologies), HRT (Heidelberg) or RTA (Talia), Medicare will pay us for care that we bill under code 92135. Medicare also reimburses many practices when they use these instruments for
nonglaucoma-related cases (e.g., confirming a diagnosis of cystoid macular edema). Note: these devices have multiple but not necessarily identical uses.
But with some commercial health plans, the coverage and reimbursement situations are anything but clear and tend to vary. Some plans refuse to pay 92135 in all cases, deeming it experimental or investigational, or they deny the code as "screening" for glaucoma.
In Aetna's case, it seems to base denials on an outdated Preferred Practice Pattern (PPP) from the American Academy of Ophthalmology
(AAO). And though the AAO updated the Primary Open Angle Glaucoma PPP last year to include results of recent studies showing the benefits of these new technologies, claims processing personnel at Aetna continue to refer practices to a policy published on Aetna's Web site
Of course, these denials run contrary to Medicare's protocols, which will surely pose a significant problem for doctors, staff and patients. Some payers do recognize the new technologies and reimburse for 92135. Others state that 92135 is a noncovered service and is therefore not subject to payment by the plan, but they also make it clear that practices may bill the patient for the service if they first meet certain conditions. (The practice must inform the patient that insurance won't cover the service, and the practice must also obtain and place in the chart a signed patient agreement to pay for the service before the practice supplies it.)
Still, other plans tell practices that 92135 isn't covered, yet upon appeal they'll (inconsistently) pay the claim. That consistent inconsistency leaves the practice in limbo during the patient visit and throughout the claims processing and appeals period. But things can get particularly frustrating and irritating when a plan allows the practice to bill a patient for noncovered services but then tells the patient that 92135 is covered (i.e., provided at no charge) while simultaneously telling the practice that it's not.
Any time a payer rejects a claim as noncovered and that rejection seems based on flawed logic or misinformation, you'll immediately need to appeal the rejection. That's the first part of a bifurcated approach to getting paid. (I've also included a sample letter, on page 52, that you can use as a model for appeals to any insurance company).
Contact and use your instrument suppliers (they have the latest research and clinical test data), state and national societies (as your professional advocates), state and federal legislators (especially those on healthcare committees), patients (insurance companies don't like to hear from disgruntled members) and employers (insurance companies also don't like to hear complaints from their customers).
Still, assuming the payer won't pay despite your best efforts to "educate," you're forced to look to the patient for payment, and that's the second side of this bifurcated approach to payment. To determine the proper protocols and your right to pursue the patient for payment, go back to the Provider Agreement. It should contain statements about covered and noncovered services and, hopefully, a definitive assertion that you may collect payment from a patient for any services not covered by his insurer.
The Provider Agreement may also contain some preconditions to billing and collecting from the patient. I described the most common earlier (i.e., informing the patient in advance that his benefit plan doesn't cover the service and obtaining in writing the patient's acknowledgement of financial responsibility).
Many payers take the position that if you don't get the patient's signed agreement in advance then you're out of luck afterward. But at least if the Provider Agreement and/or a Provider Manual (which has been incorporated by reference) documents your right to bill the patient, then you're on the correct path.
When it gets really ugly
Now what happens when a plan states that it won't pay for a service because it deems the care not medically necessary or "experimental" as Aetna does with 92135, and you're also told you can't bill the patient -- perhaps despite verbiage in the Provider Agreement that you can bill for noncovered services? Does the plan instead expect you to fall back to an older, less sophisticated technology -- in this case one that may not provide the early detection and confirmation capabilities of
SCODI? Or does it expect you to provide the "experimental" service for free, without compensation from either the plan or patient?
To provide the best possible care and be compensated for 92135, what must you do to improve your chances of collecting when the plan won't pay?
Get every commercial insurance patient to sign a consent form up front (in case the payer deems something
noncovered. The safest, short-term tactic is to have every commercial insurance patient sign a document you create that's similar to Medicare's Advanced Beneficiary Notice
(ABN). This document causes a patient to acknowledge that if his insurance doesn't cover the service or procedure for any reason then he accepts financial responsibility. (Get your attorney's guidance on the exact wording so as not to conflict with federal or state laws or other contractual language.)
Amend current and future Provider Agreements.
You'll eliminate all sorts of hassle if you can get a plan to remove the contract language requiring your practice to get a patient's prior written agreement to pay for any services deemed noncovered by the payer. Some plans will agree to this (although they certainly won't volunteer that willingness, so ask).
Striking that notification and pre-authorization obligation is critical because removing the requirement allows the practice to bill the patient once a payer notifies the practice of any denial as
noncovered. Also this way, the payer doesn't penalize the practice for failing to obtain a signature at the time of service.
Obviously, it's a good idea to educate the patient at the time of service and to document in the chart that you discussed the possibility of financial responsibility if the plan doesn't pay for a service. But you shouldn't be penalized for failure to do so.
Of course, you're likely to encounter resistance from some plans that will say the notification language is intended to protect the members. But you're only asking for an uncomplicated means to bill for noncovered services that you provide based on best professional judgment.
If you think about the underlying purpose of your Provider Agreement, it makes sense to drop the requirement, and the logic should be clear to any payer. Remember that the terms of your agreement with a payer are supposed to limit the patient's financial responsibility on covered services. For example, you can collect co-payments and deductibles from the patient, but you can't balance bill any amount discounted by the plan. And that's all fine -- as long as your obligations are limited to those dealing with covered services.
O.D., of Hawthorne, N.J., says he and several clients have been told by third-party payers that the procedure (scanning computerized ophthalmic diagnostic imaging) is experimental and therefore not covered.
He says, "Currently more than 800 positive, peer-reviewed clinical studies demonstrate the diagnostic value of HRT (Heidelberg), OCT
(Zeiss) and GDx (Laser Diagnostic Technologies)." Dr. Gerber offers two solutions to the problem of third-party payers that refuse reimbursement:
1. Have the patient sign a financial responsibility acknowledgement form
2. Don't deal with insurance at all.
"My choice for clients has generally been option 2," says Dr. Gerber. "Explain to patients that 'this is an important test and regardless of what your insurance company says, you need it.' It shouldn't be much more complicated than that."
But in my opinion (and that of many others), except for any mandated language, the Provider Agreement shouldn't interfere with patient/practice dealings on noncovered services because those are outside the scope of the document. In other words, if the plan isn't going to pay, then it shouldn't interfere with the practice and the patient settling the bill.
This is a win-win proposal -- one that plans should agree to because it gives something important to the practitioner at no added cost to the plan. It's beneficial for the practice because eliminating the blanket requirement to obtain advance signatures reduces your administrative hassle and paperwork. And making the practitioner's life simpler is a rare accomplishment for payers these days.
However, what's logical and eminently reasonable to practitioners sometimes won't fly with particularly difficult payers. If a payer refuses to change the problematic language in your Provider Agreement, then consider that a warning flag going up. Evaluate just how much you need that contract.
It's essential that every practice caught up in this 92135 non-payment nightmare put pressure on the manufacturers of the instruments. They're the ones who sold you the technology with the promise (actual or alluded) that your practice would be able to collect for services rendered.
Wherever possible, manufacturers should advocate directly with the payers. Or, if payers refuse to entertain their efforts, then the manufacturers should support yours by supplying the clinical documentation necessary to show that the care provided with this more advanced technology is appropriate, effective and in the patients' best interests.
Part of the educational effort must center on helping payers understand how four different technologies can all be included within a single CPT code. It's probably not all that surprising payers are confused when some practices might appeal glaucoma-related claims for use of the HRT to do topography of the optic nerve head while others use the GDx for nerve fiber layer analysis. (Note that using these instruments for retina care opens a different set of issues than when they're used for glaucoma.)
Unless the manufacturers get on board 100% in this effort and supply additional, convincing evidence, then Aetna and Blue Cross/Blue Shield and others will continue to tell doctors that their cutting-edge care isn't necessary or is clinically no better and/or no more appropriate than other available technologies.
Appeal every unreasonable denial of 92135. This is the standard of care today in the ophthalmic industry, and for any payer to reject the technology as experimental or investigational or screening flies in the face of current evidence.
But payers can deny or only partially pay any of your claims for a wide variety of reasons. So when appealing any claim denied in full or in part, you'll want to have all of your ducks in a row to support your position and to make it harder for the plan to deny the resubmission. Here's a checklist of key points:
- Was the patient an eligible member of the health plan on the date you provided service?
- Was the service a "covered service" as defined by your Provider Agreement?
- Was the patient eligible for and entitled to the specific covered service provided on that date? (That is, were there any plan limitations on the number of services available to the patient?)
- Did the covered service require a pre-authorization or any other form of certification before you rendered care, and did you attach such confirmation to the claim?
- Did staff code the claim appropriately? Did the claim include all required chart documentation to support the level of service?
- Was the claim submitted within the timeframe specified in your Provider Agreement?
- Did staff collect any applicable co-payments, deductibles or co-insurance, and were the amounts documented with the claim?
- Did your staff submit the claim on the approved form, or in the approved format?
- Did claim include all required patient demographic information?
- Did you attach available scientific documentation to counter any denial deeming a service "experimental, investigational," or for any other similar reason?
Contributing editor Mr. Weber is a
nationally recognized author, lecturer and practice management consultant to practitioners and to the managed care and ophthalmic industries. He has served as director of Managed Care for the American Academy of Ophthalmology. You can reach him at (954) 915-6771 or at
Optometric Management, Issue: July 2004