Problems with denials from BCBS

[EtherBunny]

It seems like I'm having a disproportionately high rate of denials for just about everything from BCBS, from MRI scans to procedures. Anyone else encountering the same issues with Blue Cross? It's ridiculous.

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[kamilo6]

Which state are you in?
Also, is this something that just happened?
Our billers just emailed us huge list of out of the ordinary denials (but from all payers).

 

[tmvguy03]

It seems like I'm having a disproportionately high rate of denials for just about everything from BCBS, from MRI scans to procedures. Anyone else encountering the same issues with Blue Cross? It's ridiculous.

YUP. I am literally on hold right now for a P2P for a transforaminal.....hope the "doctor" answers soon so I can get this over with, they're putting my stim patient on the table in 10min....

 

[thecentral09]

Yes, in PA they switched all prior auths to evicore and it takes hours to enter the appropriate info and receiving responses has taken weeks in some circumstances.

 

[emd123]

It seems like I'm having a disproportionately high rate of denials for just about everything from BCBS, from MRI scans to procedures. Anyone else encountering the same issues with Blue Cross? It's ridiculous.

Yep. Blue Cross has been f***ing horrible the last 2 years, but even more so the last few months. They went from being our best, to our worst. Crap insurance for pain.

 

[No Pain All gain]

Probably just delaying until deductibles reset. Corporate manipulation. As if record profits weren’t enough.


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[SommeRiver]

Evicore is unbelievable. Terrible human beings.

 

[Dr. Ice]

Probably just delaying until deductibles reset. Corporate manipulation. As if record profits weren’t enough.


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This

 

[painfree23]

Evicore is unbelievable. Terrible human beings.

This too

 

[geauxg8rs]

This too

Somebody tried to deny for lack of recent PT. Despite me documenting, the P2P told me it had to be 6 weeks within last month. When I said “that is impossible”, they didn’t get it. Just can’t win

 

[pastafan]

Somebody tried to deny for lack of recent PT. Despite me documenting, the P2P told me it had to be 6 weeks within last month. When I said “that is impossible”, they didn’t get it. Just can’t win

Send them for chiropractic manipulation. I'm sure there is a chiropractor that can bill for 6 weeks within a month.

 

[cowboydoc]

I recently had a few denials for RFA of C2/3 after approval of 2 MBBs. Couldn't produce a study isolating lack of efficacy for C2/3 vs other levels.

I brought one of them back for just the 3/4 level which didn't cover his pain, so I dropped another needle and made sure some lido drifted north to cover C2/3. Submitted for C3/4 RFA, which they denied because of lack of recent PT.

It would be comical if it weren't so infuriating.

 

[callmeanesthesia]

I find it helpful if I fish around when talking to the patient, ask if they’ve done PT or chiropractic recently, and if they’ve been doing any exercises or stretches recommended by those people. I then document (assuming they have) that the patient has completeda combination of physical therapy, chiropractic, and directed home exercises totaling at least 6 weeks within the past 6 months.

 

[bigyihoroi]

Same here in NE and CA. We don't even contract with BC now cuz of low compensation.

 

[gaseous_clay]

I find it helpful if I fish around when talking to the patient, ask if they’ve done PT or chiropractic recently, and if they’ve been doing any exercises or stretches recommended by those people. I then document (assuming they have) that the patient has completeda combination of physical therapy, chiropractic, and directed home exercises totaling at least 6 weeks within the past 6 months.

They have asked me for PT records if they can’t pull it up in their claims database.

 

[thecentral09]

They have asked me for PT records if they can’t pull it up in their claims database.

We have to do this daily

 

[Ducttape]

welcome to the club. Evicore has been in my neck of the woods for the last 3-4 years.


i find it helpful to put the exercises in the discharge instructions and specifically state in my note "physician directed home exercise program initiated today by myself".

 

[SommeRiver]

I asked an Evicore guy during a P2P how I'm supposed to offer PT for 6 weeks of the pt is having to pay $40 per visit and is on fixed income. He goes, "Well, you just gotta hang it out there like a carrot."

Okay bruh, but last time I documented an MD guided home plan yall moaned bc it needed to be formal therapy with documentation from the therapists, so which is it?

 

[mazinger]

We dropped BCBS as for all these reasons

 

[callmeanesthesia]

So, I’m in Northern California. I’m fairly new to practice. I haven’t had as bad an issue with denials from them as you do but I always thought private would reimburse more. I looked at our rates for office visits and BC and BS are significantly lower than Medicare. Is that usual? Do they just reimburse higher for procedures? The business manager told me it’s because BC and BS dominate the private insurance market in our area so we pretty much have to take what they offer.

 

[Ducttape]

I asked an Evicore guy during a P2P how I'm supposed to offer PT for 6 weeks of the pt is having to pay $40 per visit and is on fixed income. He goes, "Well, you just gotta hang it out there like a carrot."

Okay bruh, but last time I documented an MD guided home plan yall moaned bc it needed to be formal therapy with documentation from the therapists, so which is it?

You document you did MD guided. (if indeed you did).

It’s up to insurers if they will accept. So far, evicore has been accepting. Same with Medicaid plans...

 

[SommeRiver]

You document you did MD guided. (if indeed you did).

It’s up to insurers if they will accept. So far, evicore has been accepting. Same with Medicaid plans...

They do NOT always accept a physician guided plan.

Edit - As in, a sheet of paper that goes through several different exercises.

 

[SSdoc33]

it is a complete racket, and i tear in the P2P docs when i get them on the phone (which i try to avoid like the plague). typically, there is a denial, and then a peer to peer id with someone else. they claim ignorance when i get them on the phone (because THEY arent the ones who personally denied the claim), but they are still getting money from the insurance behemoth for denying care. some of us here work for these charlatans. a word to the wise: you are on the wrong side

 

[emd123]

it is a complete racket, and i tear in the P2P docs when i get them on the phone (which i try to avoid like the plague). typically, there is a denial, and then a peer to peer id with someone else. they claim ignorance when i get them on the phone (because THEY arent the ones who personally denied the claim), but they are still getting money from the insurance behemoth for denying care. some of us here work for these charlatans. a word to the wise: you are on the wrong side

This is an insult to charlatans

 

[Ducttape]

this is what Evicore states:

Clinical re-evaluation is required prior to consideration of advanced diagnostic imaging to document failure of significant clinical improvement following a recent (within 3 months) six week trial of provider-directed conservative treatment. Clinical re-evaluation can include documentation of a face-to-face encounter or documentation of other meaningful contact with the requesting provider’s office by the patient (e.g. telephone call, electronic mail or messaging).

 Provider-directed conservative treatment may include rest, ice, compression, and elevation (R.I.C.E.), non-steroidal anti-inflammatories (NSAIDs), narcotic and nonnarcotic analgesic medications, oral or injectable corticosteroids, viscosupplementation injections, a provider-directed home exercise program, crosstraining, and/or physical/occupational therapy or immobilization by splinting/casting/bracing

this is my smartphrase:

We are asking for authorization for:




MRI scan of the *** spine, without contrast.



Initial clinical evaluation performed.


 A face-to-face evaluation within the last 60 days. YES

 The initial evaluation is not required within the last 60 days if another face-to-face evaluation was performed in that time frame. This may be satisfied by the initial evaluation, re-evaluation or another visit.

Failure of recent (within 3 months) 6-week trial of physician-directed treatment and/or observation YES

Clinical re-evaluation after treatment period (may consist of a face-to-face evaluation or other meaningful contact, see (SP 1.1). YES

For spinal stenosis, see (SP 9.1)



- Patient has undergone 6 weeks of physician supervised treatment, and was seen in follow up and re-evaluation without clinically significant improvement in the patient's condition.


- The following therapies have been trialed:

6 weeks of conservative self-management including lifestyle changes.

6+ weeks of physical therapy and/or a physician directed home exercise program.

6 weeks of nonsteroidal antiinflammatory agents and/or muscle relaxants




None of these therapies provided clinically meaningful improvement in pain or functionality.


- The patient is a candidate for interventions such as injections or surgery.





The following Red Flag Indicators are currently present:

N/A



Red Flag Indications include:


o Motor Weakness

o Aortic Aneurysm or Dissection

o Cancer

o Cauda Equina Syndrome

o Fracture

o Infection

o Severe Radicular Pain

 

[SSdoc33]

this is what Evicore states:

this is my smartphrase:

your notes must be 7 pages of irrelevant data and 1/2 page of relevant data. i hate how medicine is trending. and im not yet mid-career

 

[Ducttape]

yes.

but fortunately its only a few clicks of the mouse.

 

[SSdoc33]

yes.

but fortunately its only a few clicks of the mouse.

for you. and 5 minutes of sifting through BS for anyone trying to read it.

 

[Ducttape]

I'll summarize my usual note for you here, so you don't have to look elsewhere:

"1. Not appropriate for COT given past misuse/poor functionality/poor psychological indicators
2. Poor tolerance for injections in past and unwillingness to undergo any procedures
3. all medications have caused significant side effects and patient refuses non-opioid medications
4. CBT, home exercise recommended, but they increased pain
5. patient still wants oxy
6. info given on other pain clinics and suboxone clinics"

 

[soccrwz]

I'll summarize my usual note for you here, so you don't have to look elsewhere:

"1. Not appropriate for COT given past misuse/poor functionality/poor psychological indicators
2. Poor tolerance for injections in past and unwillingness to undergo any procedures
3. all medications have caused significant side effects and patient refuses non-opioid medications
4. CBT, home exercise recommended, but they increased pain
5. patient still wants oxy
6. info given on other pain clinics and suboxone clinics"

lol

 

[BobLoblaw78]

I find the P2P to be more wasteful of time as usually they just state that it is okay to proceed once I give them the "missing" information (straight from the note). I assume that some people don't schedule the P2P and accept the denial.