kypho denials

[powermd]

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Are any of you seeing an unexpected rise in Medicare clawbacks on kyphoplasty? I've never seen this and I have two cases now this past year, which I am only now discovering. No idea how to appeal these, but I'm going to learn. I'm also finally going to hire an actual biller to oversee the manager hold buckets in Athena. We're also seeing clawbacks from Aetna stating that procedures weren't authorized, and the auth numbers we have aren't valid.

 

[Gnarvin]

I haven’t had any yet that I am aware of. However, I also have the Medicare LCD handy at my desk and always make sure I list off the criteria they meet to qualify for the kyphoplasty in my note.

I also find the Medicare LCD excessively restrictive regarding who qualifies to get a kyphoplasty.

 

[powermd]

I haven’t had any yet that I am aware of. However, I also have the Medicare LCD handy at my desk and always make sure I list off the criteria they meet to qualify for the kyphoplasty in my note.

I also find the Medicare LCD excessively restrictive regarding who qualifies to get a kyphoplasty.

My notes go through the LCD line item by item and how the patient meets criteria. They're either not looking at the notes, or don't care. The notes WERE submitted.

 

[Laryngospasm]

Lots of denials that are clearly not reading the notes.

 

[mille125]

It's intimidation

 

[mille125]

Are any of you seeing an unexpected rise in Medicare clawbacks on kyphoplasty? I've never seen this and I have two cases now this past year, which I am only now discovering. No idea how to appeal these, but I'm going to learn. I'm also finally going to hire an actual biller to oversee the manager hold buckets in Athena. We're also seeing clawbacks from Aetna stating that procedures weren't authorized, and the auth numbers we have aren't valid.

I dont use Athena but I know many that do. The theme is that if you trust Athena to manager AR without monitoring them closely you are losing money.

 

[powermd]

I dont use Athena but I know many that do. The theme is that if you trust Athena to manager AR without monitoring them closely you are losing money.

Independent audits are important. I had one earlier this year and it looked good. If you're good at billing and don't give insurance companies easy outs for denials, it helps a lot. There are annoying nitpicky things that need close attention though. For example, BCBS decided on a whim to start paying me with VCCs. Athena does not process these. Once I noticed this, I set up EFT with BCBS (umm... wasn't that already set up???), and opted out of VCC. BCBS assured me that the old VCC payments would be converted to EFT. Now I need to find a way to verify that happened, and then follow up with them. Hence my interest in finally hiring an outside biller. This is too much.

 

[Laryngospasm]

Independent audits are important. I had one earlier this year and it looked good. If you're good at billing and don't give insurance companies easy outs for denials, it helps a lot. There are annoying nitpicky things that need close attention though. For example, BCBS decided on a whim to start paying me with VCCs. Athena does not process these. Once I noticed this, I set up EFT with BCBS (umm... wasn't that already set up???), and opted out of VCC. BCBS assured me that the old VCC payments would be converted to EFT. Now I need to find a way to verify that happened, and then follow up with them. Hence my interest in finally hiring an outside biller. This is too much.

This 100%.. and that is one insurance company. It’s getting ridiculous.

 

[mille125]

Independent audits are important. I had one earlier this year and it looked good. If you're good at billing and don't give insurance companies easy outs for denials, it helps a lot. There are annoying nitpicky things that need close attention though. For example, BCBS decided on a whim to start paying me with VCCs. Athena does not process these. Once I noticed this, I set up EFT with BCBS (umm... wasn't that already set up???), and opted out of VCC. BCBS assured me that the old VCC payments would be converted to EFT. Now I need to find a way to verify that happened, and then follow up with them. Hence my interest in finally hiring an outside biller. This is too much.

They tried that on me but they said that they were going to start doing it unless I objected. My biller and I caught it and stopped it before implementation.

Why would you pay 2-3 percent cc fees on money that you already had to wait 45 to 60 days to get?

 

[powermd]

They tried that on me but they said that they were going to start doing it unless I objected. My biller and I caught it and stopped it before implementation.

Why would you pay 2-3 percent cc fees on money that you already had to wait 45 to 60 days to get?

You gave me his contact info a while back, I just emailed him.

 

[Taus]

I am pretty much expecting to get a Medicare kypho audit as I went from doing zero to >100 cases/year over the last 2 years. Every single case has that insurers criteria in the office note, MRI report in chart confirming acute/subacute and dexa in chart.

Have seen some shenanigans already… Ibc denies payment 2 to 3 months after submitted, stating no authorization was obtained. It takes my billing department hours on the phone with the rep to finally confirm that no, indeed they have the authorization…. Then another month or two to get paid. Every.single.time.

Aetna, with written prior authorization, also issues a denial about three months after charges submitted/accepted, then requests records, including op report. They don’t allow us to submit the operative report along with or shortly after submitting for payment. This has also happened every.Single.time!

It is absolutely absurd

 

[mille125]

I am pretty much expecting to get a Medicare kypho audit as I went from doing zero to >100 cases/year over the last 2 years. Every single case has that insurers criteria in the office note, MRI report in chart confirming acute/subacute and dexa in chart.

Have seen some shenanigans already… Ibc denies payment 2 to 3 months after submitted, stating no authorization was obtained. It takes my billing department hours on the phone with the rep to finally confirm that no, indeed they have the authorization…. Then another month or two to get paid. Every.single.time.

Aetna, with written prior authorization, also issues a denial about three months after charges submitted/accepted, then requests records, including op report. They don’t allow us to submit the operative report along with or shortly after submitting for payment. This has also happened every.Single.time!

It is absolutely absurd

Yep an audit is coming but it sounds like you are prepared.

 

[BobBarker]

Get audited all of the time. Performorant is the RAC contractor for Novitas. Just had 7 recouped because they said we didn’t respond to the record request which we never got. Hopefully, will get that money back.

 

[Taus]

Yep an audit is coming but it sounds like you are prepared.

Thanks to this forum

 

[nvrsumr]

Independent audits are important. I had one earlier this year and it looked good. If you're good at billing and don't give insurance companies easy outs for denials, it helps a lot. There are annoying nitpicky things that need close attention though. For example, BCBS decided on a whim to start paying me with VCCs. Athena does not process these. Once I noticed this, I set up EFT with BCBS (umm... wasn't that already set up???), and opted out of VCC. BCBS assured me that the old VCC payments would be converted to EFT. Now I need to find a way to verify that happened, and then follow up with them. Hence my interest in finally hiring an outside biller. This is too much.

Humana charges me $5 for paper checks. Won’t let me set up ach. Have tried multiple times

I have had every Medicare kypho in last year attempt a clawback

Aetna Medicare is ridiculous and very hard to deal with Auths

 

[powermd]

Humana charges me $5 for paper checks. Won’t let me set up ach. Have tried multiple times

I have had every Medicare kypho in last year attempt a clawback

Aetna Medicare is ridiculous and very hard to deal with Auths

I would have an admin fee of $5 per visit if that were the case with an insurer. In the case of Humana, I'd just leave. They don't do much business in Maine.

 

[mille125]

I would have an admin fee of $5 per visit if that were the case with an insurer. In the case of Humana, I'd just leave. They don't do much business in Maine.

They just do Medicare business here.

If they are a tiny percentage of your patients and they cause this much trouble, I would drop them.

 

[Taus]

Humana charges me $5 for paper checks. Won’t let me set up ach. Have tried multiple times

I have had every Medicare kypho in last year attempt a clawback

Aetna Medicare is ridiculous and very hard to deal with Auths

Yep, Aetna-mc is by far the worst. No chance of auth if even 1mm of retropulsion, even on p2p. Need to get radiologist to addend report that there isn’t any. Been on p2p with neurosurgeon w Aetna-mc who is “not able” offer his clinical judgement, can only refer to their policy. What he would do clinically is “not relevant to this discussion”. Cites Medicare policy, which does allow for retro, as listed under relative, not absolute contraindication. No dice on that discussion re how they are not following Medicare LCD. I have had to get patients admitted to the hospital for pain control through the ER, procedure in the main OR, to get around this several times. Made P2P doc clearly aware that this was my plan if cannot authorize for in office, and would cost insurance dramatically more. No dice. To the hospital it is….

Previously gave 48 hours for p2p once they deny auth request…. Now they call your office once, without notice, and when they cannot get you on the phone immediately, they deny the case, with the only option being a written appeal.

Fkrs

 

[JFS]

Yep, Aetna-mc is by far the worst. No chance of auth if even 1mm of retropulsion, even on p2p. Need to get radiologist to addend report that there isn’t any. Been on p2p with neurosurgeon w Aetna-mc who is “not able” offer his clinical judgement, can only refer to their policy. What he would do clinically is “not relevant to this discussion”. Cites Medicare policy, which does allow for retro, as listed under relative, not absolute contraindication. No dice on that discussion re how they are not following Medicare LCD. I have had to get patients admitted to the hospital for pain control through the ER, procedure in the main OR, to get around this several times. Made P2P doc clearly aware that this was my plan if cannot authorize for in office, and would cost insurance dramatically more. No dice. To the hospital it is….

Previously gave 48 hours for p2p once they deny auth request…. Now they call your office once, without notice, and when they cannot get you on the phone immediately, they deny the case, with the only option being a written appeal.

Fkrs

That's also been my play-for-play experience on retropulsion with those a**holes. Probably the same neurosurgeon too.