RFA denials

[Preganglionic]

trying to manage scenario being denied payment on RFA, though they have not required prior authorization.

per policy of many carriers, if there is any other pathology present, incidental or not, like nerve root impingement.... they will deny payment of RFA after the fact, despite diagnostic response to MBB.

how are you handling the prospects of RFA denials? are you electing not to do the RFA since you may not get paid, work appeals after the fact, and/or hold patient responsible for what their policy won't cover..

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[giddyup]

We are doing letters of medical necessity after the fact. This has been working about 75% of the time. I just talked to our in-house billers last week and now for all RFA's that are not Medicare that don't require prior authorization we are going to try to get something in writing before we do them. I'll check with them tomorrow to see if they've been able to do this.

 

[Kwijibo]

We have essentially been getting a pre-determination before proceeding with RFA procedures, particularly with BCBS insurance products. We have been getting denied as 'experimental' quite a bit from BCBS when going ahead with it, as many do not require prior authorization, only to find they will not pay when we bill. Even with letters of medical necessity after the fact.
The problem is when insurances state that they do not do pre-determination for the procedure. If you want a copy of our letter just PM me.

 

[Preganglionic]

thanks so much for the input

 

[ampaphb]

I find it is helpful to ask the carrier for their authorization criteria. Once I have it, I tailor my medical necessity letter appropriately.

 

[clubdeac]

What do you do when the carrier requires facet arthropathy on imaging? Total bull****

 

[bedrock]

What do you do when the carrier requires facet arthropathy on imaging? Total bull****

Everyone over 25 has some degeneration of everything. So, my personal review of the MRI will include "mild facet degeneration" of any level that are clinically relevant on exam. I do this specifically for insurance reasons as the idiot insurance companies can't understand how microscopic damage to facet cartilage can cause pain to their insured clients.

 

[emd123]

Everyone over 25 has some degeneration of everything. So, my personal review of the MRI will include "mild facet degeneration" of any level that are clinically relevant on exam. I do this specifically for insurance reasons as the idiot insurance companies can't understand how microscopic damage to facet cartilage can cause pain to their insured clients.

Right. I usually put something like "pain is primarily axial without major radicular signs, provoked with facet maneuvers on exam, as well as confirmed by MRI which shows bilateral multilevel facet disease." Add that to the usual "conservative care, PT, meds, blah blah blah...have been tried."

All those buzzwords that the box-checking review nurse is looking for.

Sometimes I still get a denial and a peer to peer where they tell me it was denied because there was no documentation of exactly what I documented. An iInfuriating game.

 

[bedrock]

Sometimes I still get a denial and a peer to peer where they tell me it was denied because there was no documentation of exactly what I documented. An iInfuriating game.

It's a game. They'll require a peer to peer on 1 out of 8 of theses with perfect documentation, everything they ask for, because they know a certain percentage of physicians won't do peer to peer as a matter of principal, and then they'll save money on those cases. The insurance people who come up with these ideas are Scheming slimy bastards. I don't know how they sleep at night.

 

[emd123]

It's a game. They'll require a peer to peer on 1 out of 8 of theses with perfect documentation, everything they ask for, because they know a certain percentage of physicians won't do peer to peer as a matter of principal, and then they'll save money on those cases. The insurance people who come up with these ideas are Scheming slimy bastards. I don't know how they sleep at night.

Oh, I know. It's outrageous. They don't give a ---.

 

[Stim4me]

BCBS has created 'self-funded' entities in states like NJ, Illinois, and Cali. These self-funded plans are different from your state specific BCBS plans, with different authorizations and reimbursement. Always get a pre-cert, otherwise they will not pay you. Furthermore, you cannot take these plans to third level appeals or the insurance commissioner. We have deferred all RFA procedure on BCBS NJ plans period due to losses the last 2 years....
If you get a pre-cert with the buzzwords recommended above (ie no radic, >6months PT/home exercise , no fusion) they should approve it. You need a MBB block w/in a year now, as well...

 

[giddyup]

I have gotten a new slew of RFA denials after-the-fact (no auth needed) because they will hold payment and ask us to send medical records, we will send the medical records which usually includes an MRI, and if there is even minimal foraminal narrowing and they will say the pain is due to a pinched nerve and RFA is experimental for that. I have done letters of medical necessity stating that the pain is not radicular, the patient does not have physical exam signs indicating a pinched nerve, etc but they are still denying it. Anyone else have this happening lately? What kind of recourse do I have?

 

[BobBarker]

I have gotten a new slew of RFA denials after-the-fact (no auth needed) because they will hold payment and ask us to send medical records, we will send the medical records which usually includes an MRI, and if there is even minimal foraminal narrowing and they will say the pain is due to a pinched nerve and RFA is experimental for that. I have done letters of medical necessity stating that the pain is not radicular, the patient does not have physical exam signs indicating a pinched nerve, etc but they are still denying it. Anyone else have this happening lately? What kind of recourse do I have?

Your recourse is two level transforaminal series of 3.

 

[emd123]

I have gotten a new slew of RFA denials after-the-fact (no auth needed) because they will hold payment and ask us to send medical records, we will send the medical records which usually includes an MRI, and if there is even minimal foraminal narrowing and they will say the pain is due to a pinched nerve and RFA is experimental for that. I have done letters of medical necessity stating that the pain is not radicular, the patient does not have physical exam signs indicating a pinched nerve, etc but they are still denying it. Anyone else have this happening lately? What kind of recourse do I have?

Tell the patient their insurance is a rip off, taking their money and not paying out and instead is playing games. Then tell them the only solution is for them to fire the insurance company and get one that makes good on their premium. Other solution: You dump the plan and stop playing the BS games.

The only real solution is when these plans lose enough customers they change their ways.

 

[Stim4me]

I have gotten a new slew of RFA denials after-the-fact (no auth needed) because they will hold payment and ask us to send medical records, we will send the medical records which usually includes an MRI, and if there is even minimal foraminal narrowing and they will say the pain is due to a pinched nerve and RFA is experimental for that. I have done letters of medical necessity stating that the pain is not radicular, the patient does not have physical exam signs indicating a pinched nerve, etc but they are still denying it. Anyone else have this happening lately? What kind of recourse do I have?

Send the claims to your state insurance cmissioner for and independent review to overturn the bcbs denial. Typically works if not a self funded plan out of state.....

 

[Stim4me]

Send the claims to your state insurance cmissioner for and independent review to overturn the bcbs denial. Typically works if not a self funded plan out of state.....

I am personally working on an attorney to sue bcbs for two dozen rfas denied by bcbs in NJ

 

[bedrock]

I think legal action is the appropriate response when the insurance companies sink this low.

That, and you need to try to shame them on national news or news media. The worst thing is to just suck it up.

 

[pastafan]

In NJ isn't the law triple damages if an insurance company doesn't pay a valid claim? This gets into punitive damages territory.

 

[Stim4me]

There are certain states That I am seeing these self funded insurance plans. The insurance industry knows how to bypass the typical state appeals processes, and forced the physician to go after them directly. Unfortunately it will cost me to rcoup 40k... Is it worth it, not sure yet...

 

[Ducttape]

get ready....

i am starting to get denials for diagnostic MBBs.

 

[lobelsteve]

Just got Cigna to peer to peer and leave off 2nd MBB for cervical.

 

[Extralong]

Do you ever tell the patients to call their insurance companies and complain themselves? Some of them have nothing better to do then sit at home all day and call in complaints.

 

[nvrsumr]

If employed I tell them to meet with their HR and tell them how bad the insurance company sucks and have their HR call the insurance company. They care more when there are a 100 lives that they may lose.

 

[Extralong]

If employed I tell them to meet with their HR and tell them how bad the insurance company sucks and have their HR call the insurance company. They care more when there are a 100 lives that they may lose.

Genius! I didn't even think about that.

 

[pastafan]

If employed I tell them to meet with their HR and tell them how bad the insurance company sucks and have their HR call the insurance company. They care more when there are a 100 lives that they may lose.

Was having trouble getting in network with an insurer. Had patient that really wanted to continue to see me. She had HR at a fortune 500 company call and I was in network within weeks.