Your patient is moving better, breathing better or perhaps hearing better because of a surgically implanted medical device. The problem? The insurer won’t pay full price for the device. This shortfall is affecting who gets to move better, breath better or hear better.
Implanted device benefit calculation varies greatly from plan to plan. Often, payment is calculated using a average wholesale price for the device in question when the surgeon favors the newest, and often more costly, generation of the device.
Medicine advances forward or retracts on how such issues are resolved. Therefore, it is important to appeal poor reimbursement. Each appeal letter allows the surgeon to address how the device in question is most appropriate for the patient, what it offers over other available devices, and finally, what the insurance claim reviewer has to consider when calculating benefits.
Your appeal for higher reimbursement should fully explain the benefits of the device in question, citing from peer reviewed medical information and/or manufacturer literature when appropriate. However, patient-specific information should also be discussed because this information may allow the insurance reviewer to justify differing from a preferred, less costly, device. The medical information should discuss any post-surgical risks which are related to device selection.
Device reimbursement appeals should request the specific written limitation, exclusion or internal written criteria or guideline which applies to the claim calculation, including the definition of “usual, customary and reasonable” charges as it reads in the policy or plan booklet. Further, such appeals should request disclosure of the methodology used to calculate the payment and the source and age of the data and used to determine prevailing charges. Even if the source is identified, it is important to find out the age of the data, at what percentile the claim was adjusted to and if data was skewed by inclusion of claims not priced at normally prevailing rates.
Each appeal should identify any potential compliance issue regarding the carrier’s legal and/or contractual claim processing obligations. This requires being well educated on both state and federal claim processing requirements and potentially applicable disclosure standards. Some of the legal protections applicable to UCR calculations include federal and state disclosure laws related to benefit calculation disclosure, managed care access laws and state out-of-network payment requirements.
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