Last week I had the tremendous pleasure of spending two full days with a group of Rock Star OMS billers and coders from across the country. We talked about
codes, coding guidelines, insurance carriers, industry changes, the appeal process, practice management reports and the ENTIRE accounts receivable cycle from start to finish! Everyone worked so hard during those sessions and I know they walked away with more tools and knowledge to help them within their own practices to become more efficient, more strategic and more equipped to deal with insurance carriers.
One of the aha moments, and yes there were many for this group of experienced billers, was the review of medical policy guidelines and clinical policy guidelines that are available to you on the insurance carrier’s website. This information is easily accessible (in some cases it's public information). I use this tool quite often because I have found it gives me the “rule book” of the insurance
carrier’s guidelines on coverage.
To get this information you can do a search on the carrier’s website for a specific condition, type of surgery and even sometimes a specific code to get information regarding under what circumstances or what criteria is required for a procedure to be considered medically necessary and/or covered under
an insurance carrier’s plan. A search of Orthognathic surgery will bring up quite a lengthy document of the specifics that a carrier requires in order to consider coverage for a patient, for example, Aetna:
Antero-posterior discrepancies
- Maxillary/mandibular incisor relationship: overjet of 5 millimeter (mm) or more, or a 0 to negative value (norm 2 mm).
You will find this is chock full of information not only from a prior authorization standpoint (it tells you exactly what they need/want to consider coverage…even gives you the language they are looking for) but it also gives you the procedure and diagnosis codes they will consider for coverage and those they will
not.
This is an amazing resource to help you at the start of the process (prior authorization) but also at the end of the process if you have to do an appeal. Knowing the rules and guidelines of a carrier along with the codes can help you significantly as you begin to start the appeal process. First order of business, do the
CPT codes reported and the diagnosis codes reported based on the documentation in the patient record meet the carrier’s guidelines of covered services? If they do, then you can use the language in this clinical policy to assist you in the appeal. If they do not, then you have a much bigger battle to fight as to whether or not you are going to win the appeal. Personally, before I begin the process I want to know if I have a chance of winning or not. Trying to win an appeal
for a procedure that is clearly documented as not covered feels like a waste of time and resources …do you agree? Certainly, there are always exceptions to the rules (self-funded plans, etc.) but overall this is a good litmus test.
Not only are the policy guidelines helpful in these circumstances but they are also helpful in
situations where suddenly you are getting denials for procedures that have always historically been covered - when you wonder, "what’s up with that"? Have you noticed any changes with United Healthcare recently? Any change in coverage for third molar removal? You may want to check out their updated policy that became effective December 2017. It may help clarify some changes you may be seeing in your office regarding coverage, potential denials, etc.
We talked about so many things at the Andover, MA workshop and as mentioned, there were several aha moments over those two days. This was one I wanted to share with everyone! Hope you find this helpful as well!