What happens when prior auths don’t match services provided?

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I received a preauthorization from the patient’s insurance company, but the doctor turned in a charge sheet with different codes. This happens frequently. The claim was denied. Should I appeal?

You are not alone. In fact, we see this issue more frequently as some payers are increasing the prior authorization denials from CPT code only to CPT code, number of units, and diagnosis code.

Many payers will not accept appeals for payments when the prior authorization does not match the services provided. Instead, the payer will require that the authorization be changed to meet the services provided and then rebill the denied claim. Increasingly, payers are restricting the time allowed for a practice to revise these prior authorizations. It should be noted that most payers will allow reporting of fewer units or lower levels of service than have been authorized.

Of course, the best way to avoid any issues with prior authorization is to obtain an authorization that accurately reflects what will be provided. For those cases in which the physician thinks more services may be needed or more units may be required, the authorization should include all potential services or should include the maximum number of units that may be used.

For those cases in which the prior authorization does not match the services provided, we recommend a process that requires the provider to communicate as soon as possible to the appropriate staff for change in prior authorization. (Note: This may not be necessary for encounters in which the units or the service level are below that which was prior authorized.) Billing of the encounter should be held until a changed prior authorization is obtained.

We have seen many practices in which the solution to an incorrect prior authorization is to report the services that were authorized even when the medical record indicates other services were provided. For some cases, this may be the only way the claim will be paid. In these cases, we encourage you to exhaust all avenues of appeal and change in authorization to clearly notify the payer of what services were actually provided and the documented reasons for the service, accepting what you can in the end, and avoiding this in the future with the changes recommended above.

My doctor just performed his first partial cystectomy using robotic laparoscopy. This was a complicated case since the patient had previous radiation to the area. I can’t find a code for that. How should I bill it?

You are correct; there is no robotic partial cystectomy code.

However, the open code for partial cystectomy, as well as the open code for partial cystectomy, complicated, does not comment on approach. Therefore, it can be used to report the procedure performed with open surgery, laparoscopic surgery, or robotics.

We recommend that you report the surgery using code 51555 (Cystectomy, partial; complicated [eg, postradiation, previous surgery, difficult location]).

The AUA has also recommended this path. However, as always, you should check with your payer policies and develop policies for your practice that fit a standard protocol as there are many groups and payers that prefer reporting of the unlisted code instead.

I am working on a new device to assist in the instillation of drugs into the bladder. Can you tell me how a device like this will be reimbursed?

Without knowing the specifics of the device and where you are with the FDA and other regulatory hurdles, we will answer the question generally as we understand the device and how policies pertain to reimbursement of drugs and supplies used during the performance of a procedure.

The current Medicare fee schedule used by Medicare and most private payers will include payment for supplies and equipment required to complete an approved procedure. In other words, payment for procedures completed in the office will be paid to the physician’s office submitting the claim without separate facility payment and will include payment in most cases for all clinical staff, medical supplies, and equipment. One exception to this inclusion rule is payment for drugs purchased and delivered to the patient in the office, which are not typically self-administered.

Therefore, based on our understanding of your product, your delivery device would be included in the allowed amount currently listed for the CPT code used to deliver the drug (51700, 51720, etc.). The drugs delivered to the patient could be reported separately.

The ambulatory surgical center, hospital inpatient, hospital outpatient, skilled nursing facility, etc. will charge separately from the physician. The physician payment at the lower facility rate would not include supplies and/or drugs required during treatment. Instead, the facility would report a service charge related to the procedure or diagnosis that would include a bundled payment for the staff, supplies, and equipment. Again, based on our understanding of your device, no separate payment would be made to the facility for your device.

Offices interested in using your device will have to consider the cost difference between your device and the costs they have currently. In today’s market, though, cost considerations should take into account both the fee-for-service market and the value-based market pressures. In a fee-for-service market, cost considerations will focus on time for personnel, room time (opportunity cost), and device cost.

In a value-based market, the office will also need to consider the value of any increased efficacy of treatment, patient satisfaction, and long-term complication and compliance improvements. The actual dollar value of each of these issues will vary according to contract and packages.

Good luck and feel free to reach out again if we can be of more assistance.