Humana Moves Towards AEtna's Policy
by Cheryl Nash
Some of you may have noticed the new changes to the language in Humana's coverage policy. Along the lines of last year's changes to Aetna's guidelines , Humana has also added a notation in their guidelines stating:
Initially, one treatment session of RFA, TIPP or, EVLT™, per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session.
Interestingly enough, we agree that 'staging' the GSV into more than one session is rarely if ever indicated. The above statement though is being used to state treatment of both the great and short saphenous vein should be treated in the same setting. They want the claim to be billed as a 36475/36478 for the GSV and 36476/36479 for the SSV. While this is of concern, they did allow a small amount of room for leeway in the statement:
Repeat sessions of RFA, TIPP, EVLT™ or stripping/division/ligation may be requested and are subject to medical necessity review. Repeat sessions may be medically necessary for persons with persistent or recurrent junctional reflux.
We have had some varying results on recent authorizations, and like Aetna, it appears to be subject to the medical director's discretion on how stringently this is being enforced. Also of interest is that Humana excluded the treatment of perforators, tributaries, and accessory veins with either RF or EVLT, stating that these services are considered experimental and investigational. We will be following up on this development as we receive more feedback from the insurance company and our clients.
Monday, August 22, 2011
Friday, June 24, 2011
E-Perscribing Requirements
Out Clause for Phlebology
by AJ Riviezzo
One of the new(er) concerns we have been fielding of late is the Medicare decision on E-prescribing. Medicare is turning it from a small bonus to a penalty if you are not in compliance. While the 1% reduction for next year isn't large, it will increase each subsequent year.
On to the good news though. The Federal Register, Vo. 76, No. 105 dated June 1, 2011, page 31550 states:
"...the 2012 eRx payment adjustment does not apply to an individual eligible profession or group practice if less than 10 percent of an eligible professional's or groups practice's estimated total allowed charges for the Jan 1, 2011 through June 30, 2011 reporting period are comprised of services that appear in the denominator of the 2011 eRx measurer."
In summary, if your services for certain codes are less than 10% of what Medicare pays you for all of your Medicare reimbursed services, the E-Prescribe requirements do not apply. There are multiple codes but the primary ones for a phlebology practice are the 99201-99205 new patient exams and 99211-99215 office visit exams. Please contact me if you would like a copy of all of the codes (877.611.1322).
We reviewed three different phlebology practices to see if they came close to the 10% mark. Out of the three, the highest percentage was 4% with the other two less than half of that. Essentially, unless your practice was only seeing new patients and not providing US services or treatment, you likely fall well under the 10 percent mark as well. You may want to double check this assumption but I feel pretty confident that this rule will not apply to phlebology practices as it is currently written.
by AJ Riviezzo
One of the new(er) concerns we have been fielding of late is the Medicare decision on E-prescribing. Medicare is turning it from a small bonus to a penalty if you are not in compliance. While the 1% reduction for next year isn't large, it will increase each subsequent year.
On to the good news though. The Federal Register, Vo. 76, No. 105 dated June 1, 2011, page 31550 states:
"...the 2012 eRx payment adjustment does not apply to an individual eligible profession or group practice if less than 10 percent of an eligible professional's or groups practice's estimated total allowed charges for the Jan 1, 2011 through June 30, 2011 reporting period are comprised of services that appear in the denominator of the 2011 eRx measurer."
In summary, if your services for certain codes are less than 10% of what Medicare pays you for all of your Medicare reimbursed services, the E-Prescribe requirements do not apply. There are multiple codes but the primary ones for a phlebology practice are the 99201-99205 new patient exams and 99211-99215 office visit exams. Please contact me if you would like a copy of all of the codes (877.611.1322).
We reviewed three different phlebology practices to see if they came close to the 10% mark. Out of the three, the highest percentage was 4% with the other two less than half of that. Essentially, unless your practice was only seeing new patients and not providing US services or treatment, you likely fall well under the 10 percent mark as well. You may want to double check this assumption but I feel pretty confident that this rule will not apply to phlebology practices as it is currently written.
Local Coverage Determinations
Matching Tit for Tat
by AJ Riviezzo
The requirements by the various payers continue to evolve and shift. Some, like United Healthcare, have become slightly more user friendly as they finally recognized that wearing stockings for three months does absolutely nothing for a patients venous disease. Others, like the Medicare intermediary Trailblazer, have changed their guidelines and are now starting to enforce the need to place the patient in stockings and track them for three to six months.
All of these changes are necessitating changes at the practice level.
First, it is imperative that the guidelines for each payer are reviewed regularly to identify any changes. Second, these changes must be clearly understood by the physician, the medical team, and the authorization coordinator. These are the two 'easy' changes.
Third, and becoming increasingly more important, is that the documentation needs to be tailored to a certain extent to meet the payer's guidelines. For example, Trailblazer and some commercial payers require the patient to be placed in compression hose and monitored by the physician. There must be an initial review of the patient, and order placing them in stockings, a review of any relief or continued symptoms at the 45 day mark, and a similar review at the 90 day mark. All of this needs to be captured in your summary of the patient's condition as to why you are now recommending an ablation to be performed. Other payers may want you to wait 90 days before performing a phlebectomy. Again, your documentation needs to match the expectations that the patient is re-reviewed and a phlebectomy is ordered based on that follow up visit.
Unfortunately, the old adage that "if you didn't document it, you didn't do it" is becoming the rule even before you are authorized to treat the patient.
by AJ Riviezzo
The requirements by the various payers continue to evolve and shift. Some, like United Healthcare, have become slightly more user friendly as they finally recognized that wearing stockings for three months does absolutely nothing for a patients venous disease. Others, like the Medicare intermediary Trailblazer, have changed their guidelines and are now starting to enforce the need to place the patient in stockings and track them for three to six months.
All of these changes are necessitating changes at the practice level.
First, it is imperative that the guidelines for each payer are reviewed regularly to identify any changes. Second, these changes must be clearly understood by the physician, the medical team, and the authorization coordinator. These are the two 'easy' changes.
Third, and becoming increasingly more important, is that the documentation needs to be tailored to a certain extent to meet the payer's guidelines. For example, Trailblazer and some commercial payers require the patient to be placed in compression hose and monitored by the physician. There must be an initial review of the patient, and order placing them in stockings, a review of any relief or continued symptoms at the 45 day mark, and a similar review at the 90 day mark. All of this needs to be captured in your summary of the patient's condition as to why you are now recommending an ablation to be performed. Other payers may want you to wait 90 days before performing a phlebectomy. Again, your documentation needs to match the expectations that the patient is re-reviewed and a phlebectomy is ordered based on that follow up visit.
Unfortunately, the old adage that "if you didn't document it, you didn't do it" is becoming the rule even before you are authorized to treat the patient.
Audit Alert
More Fun by a Payer
by Cheryl Nash
Humana has started issuing letters requesting medical records for an audit of their Medicare Advantage Plan members. We have received information of from two providers in phlebology practices that have received the same request - in different states. This appears to be a random audit to compare to current medical necessity and correct coding guidelines.
If a request of this nature is received, all records should be pulled and copied, placed in chronological order, and checked for completeness prior to submitting. Submission will need to be timely as there is typically a deadline for compliance.
We recommend doing an internal audit of your Humana Medicare patient's charts to ensure your records are complete. If there is something missing but the information is captured on a different form in the chart, you can provide an addendum to something like the History and Physical. The addendum needs to be clearly dated with the current date and signed. However, the information should be present in the chart already and cannot be created whole cloth into the chart.
Humana's Medicare Advantage plans follow your local LCD policies; these can be found through the following link;http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
by Cheryl Nash
Humana has started issuing letters requesting medical records for an audit of their Medicare Advantage Plan members. We have received information of from two providers in phlebology practices that have received the same request - in different states. This appears to be a random audit to compare to current medical necessity and correct coding guidelines.
If a request of this nature is received, all records should be pulled and copied, placed in chronological order, and checked for completeness prior to submitting. Submission will need to be timely as there is typically a deadline for compliance.
We recommend doing an internal audit of your Humana Medicare patient's charts to ensure your records are complete. If there is something missing but the information is captured on a different form in the chart, you can provide an addendum to something like the History and Physical. The addendum needs to be clearly dated with the current date and signed. However, the information should be present in the chart already and cannot be created whole cloth into the chart.
Humana's Medicare Advantage plans follow your local LCD policies; these can be found through the following link;http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
Tuesday, April 12, 2011
Conservative Treatment Changes
Documenting Stockings
by Cheryl Nash and AJ Riviezzo
In the past the patient report regarding the wearing of compression stockings was sufficient. Unfortunately, a passing 'nod' is no longer sufficient by a growing list of payers. With the Phlebology requirements becoming more and more payer specific, a trend has been emerging that may change the way you document conservative treatment.
In the past if a patient stated that they had worn compression stockings and tried other forms of conservative treatment, (leg elevation, exercise, NSAIDS, etc.) this information alone was sufficient to support medical necessity. The trend in the clinical guidelines now state that the medical record includes physician office notes indicate failure of medically supervised conservative management, including but not limited to compression stocking therapy for. (Excerpt from Cigna Medical Coverage Policy #0234).
The terms about this type of requirement vary. It is sometimes called medical management, supervised trial, or ordered by the treating physician. It all translates to the same end result. You must place the patient in compression hose and follow the patient's conservative therapy for the (typically) 90 days.
Obviously this causes some issues in scheduling timelines for treatment, but after the initial stall with these payers, this should even out. When doing a supervised trial, the patient should be brought back into the office at intervals to assess the success or failure of the conservative treatment and at the end of the trial. If appropriate, a new diagnostic US to clearly show that the symptoms and disease has not changed would be indicated. (Please check your payer policy to ensure that there are no limitations on this service as well.)
You may also want to consider selling the compression hose in your office. While some payers do not cover the stockings, others do. By selling, and then submitting the claim to their insurance plan, you have another record that the patient did indeed have the hose with them when leaving your office.
While this has language has been around for a while, it was mainly confined to isolated local payers. With this addition to Cigna's policy, as well to various Medicare guidelines and several of the Blues plans, it has now "made the big time".
As always, we at American Physician cannot stress enough; check your payer's policies often to ensure you are meeting their guidelines!
by Cheryl Nash and AJ Riviezzo
In the past the patient report regarding the wearing of compression stockings was sufficient. Unfortunately, a passing 'nod' is no longer sufficient by a growing list of payers. With the Phlebology requirements becoming more and more payer specific, a trend has been emerging that may change the way you document conservative treatment.
In the past if a patient stated that they had worn compression stockings and tried other forms of conservative treatment, (leg elevation, exercise, NSAIDS, etc.) this information alone was sufficient to support medical necessity. The trend in the clinical guidelines now state that the medical record includes physician office notes indicate failure of medically supervised conservative management, including but not limited to compression stocking therapy for
The terms about this type of requirement vary. It is sometimes called medical management, supervised trial, or ordered by the treating physician. It all translates to the same end result. You must place the patient in compression hose and follow the patient's conservative therapy for the (typically) 90 days.
Obviously this causes some issues in scheduling timelines for treatment, but after the initial stall with these payers, this should even out. When doing a supervised trial, the patient should be brought back into the office at intervals to assess the success or failure of the conservative treatment and at the end of the trial. If appropriate, a new diagnostic US to clearly show that the symptoms and disease has not changed would be indicated. (Please check your payer policy to ensure that there are no limitations on this service as well.)
You may also want to consider selling the compression hose in your office. While some payers do not cover the stockings, others do. By selling, and then submitting the claim to their insurance plan, you have another record that the patient did indeed have the hose with them when leaving your office.
While this has language has been around for a while, it was mainly confined to isolated local payers. With this addition to Cigna's policy, as well to various Medicare guidelines and several of the Blues plans, it has now "made the big time".
As always, we at American Physician cannot stress enough; check your payer's policies often to ensure you are meeting their guidelines!
Blues Audit to Recoup $72,000
A Cautionary Tale
by AJ Riviezzo
A provider was audited by the Blues in their home state. They reviewed twenty charts. Not very many overall. Based on these twenty charts the determined that the level of coding for new patient and current patient office visits was not supported by the documentation. The Blues determined that instead of a 3 level code, they would only allow a 1 or 2 level code.
A dollar difference was determined and then applied to ALL of the office visit codes for the past three years. While an office visit may not be a large dollar item, and while the difference between the 2 level and the 3 level codes is not large either; when multiplied by a large number of office visits for three years... the dollar figure does indeed become large.
Given the various Medicare audits and the increasing reality of commercial audits, it is critical to ensure your charts match your coding.
Please have someone external review your charting. It is difficult to 'proof' your own work with an objective eye. In the above example the physician was spending a good bit of time with each patient. As such, this good doctor fully believe that this would justify the code levels selected. An internal audit would have supported that conclusion. Unfortunately an external audit conducted by personnel who do not already 'know' how much time is being spent will derive a different determination.
The above information is not designed to drum up business for my company. Please just use someone with good coding training that is external to your system to perform a bill-to-chart audit.
by AJ Riviezzo
A provider was audited by the Blues in their home state. They reviewed twenty charts. Not very many overall. Based on these twenty charts the determined that the level of coding for new patient and current patient office visits was not supported by the documentation. The Blues determined that instead of a 3 level code, they would only allow a 1 or 2 level code.
A dollar difference was determined and then applied to ALL of the office visit codes for the past three years. While an office visit may not be a large dollar item, and while the difference between the 2 level and the 3 level codes is not large either; when multiplied by a large number of office visits for three years... the dollar figure does indeed become large.
Given the various Medicare audits and the increasing reality of commercial audits, it is critical to ensure your charts match your coding.
Please have someone external review your charting. It is difficult to 'proof' your own work with an objective eye. In the above example the physician was spending a good bit of time with each patient. As such, this good doctor fully believe that this would justify the code levels selected. An internal audit would have supported that conclusion. Unfortunately an external audit conducted by personnel who do not already 'know' how much time is being spent will derive a different determination.
The above information is not designed to drum up business for my company. Please just use someone with good coding training that is external to your system to perform a bill-to-chart audit.
CIGNA Changes
More Fun by a Payer
by AJ Riviezzo
Our friends at CIGNA are now placing a limitation of services on their policies (those that even have ablations allowed in the first place). They will only authorize two vein treatments per year. There is an exception as you may call to re-authorize if there is a compelling need.
For example, Ms. Smith needs both GSV's and SSV's treated. You decide to authorize and treat the two GSV's. Now, at the one month follow-up visit, Ms. Smith's SSV's show no improvement and she still complains of pain, swelling and night-cramps. You may be able to get this treatment authorized but it will require another request and likely further documentation. Dependent on how the guidelines are being interpreted, you may have to hold a peer-to-peer conversation with the CIGNA Medical Director.
CIGNA has also recently announced in one of their online newsletters that the focus for audits this year is... Evaluation and Management coding. In keeping with our article above, please ensure your documentation is bullet proof. Everyone appears to have focused on this area this year. Not because of the high dollars but because of the ease in which they can find fault. Even if you are using an EMR, there can still be some nuances that are missed. Please have your work proofed.
by AJ Riviezzo
Our friends at CIGNA are now placing a limitation of services on their policies (those that even have ablations allowed in the first place). They will only authorize two vein treatments per year. There is an exception as you may call to re-authorize if there is a compelling need.
For example, Ms. Smith needs both GSV's and SSV's treated. You decide to authorize and treat the two GSV's. Now, at the one month follow-up visit, Ms. Smith's SSV's show no improvement and she still complains of pain, swelling and night-cramps. You may be able to get this treatment authorized but it will require another request and likely further documentation. Dependent on how the guidelines are being interpreted, you may have to hold a peer-to-peer conversation with the CIGNA Medical Director.
CIGNA has also recently announced in one of their online newsletters that the focus for audits this year is... Evaluation and Management coding. In keeping with our article above, please ensure your documentation is bullet proof. Everyone appears to have focused on this area this year. Not because of the high dollars but because of the ease in which they can find fault. Even if you are using an EMR, there can still be some nuances that are missed. Please have your work proofed.
Wednesday, February 23, 2011
Insurance Plan Riders
Sneaky Exclusions
by AJ Riviezzo and Cheryl Nash
We have seen a growing use of 'riders' for self funded plans. To help keep premium costs low, these self funded plans have carved a number of niches or riders out of the normal plan. We have seen a growing number of these riders being focused on varicose vein treatments. In short with these riders, the patient has no coverage or may have very different benefits.
The difficulty is that the administering plan's front line people are unaware of these riders and frequently give incorrect benefit information. While you can sometimes use a complaint about incorrect information to eventually get paid, it is, at best, a gamble that takes up to a year to pay off.
If you are working with payers that typically administer self funded plans who may have a rider (CIGNA, Multiplan, some Blues plans), you may want to verify a little bit more. Ask the clerk if this is a 3rd party administered plan and if there are any exclusions. You may want to go ahead and have the claim reviewed by the pre-determination folks for that payer to ensure payment. We realize these extra steps take time and effort, but it is much better than giving care away unintentionally.
by AJ Riviezzo and Cheryl Nash
We have seen a growing use of 'riders' for self funded plans. To help keep premium costs low, these self funded plans have carved a number of niches or riders out of the normal plan. We have seen a growing number of these riders being focused on varicose vein treatments. In short with these riders, the patient has no coverage or may have very different benefits.
The difficulty is that the administering plan's front line people are unaware of these riders and frequently give incorrect benefit information. While you can sometimes use a complaint about incorrect information to eventually get paid, it is, at best, a gamble that takes up to a year to pay off.
If you are working with payers that typically administer self funded plans who may have a rider (CIGNA, Multiplan, some Blues plans), you may want to verify a little bit more. Ask the clerk if this is a 3rd party administered plan and if there are any exclusions. You may want to go ahead and have the claim reviewed by the pre-determination folks for that payer to ensure payment. We realize these extra steps take time and effort, but it is much better than giving care away unintentionally.
AETNA Clinical Bulletin
Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
Authorizations
Grab a Bunch
by AJ Riviezzo
When obtaining the authorization for the ablation, we also recommend obtaining the authorization for any additional services you routinely provide. Let us presuppose in your practice you average one phlebectomy for every two ablations and one to two medically necessary sclero procedures for every ablation. When obtaining the authorization for the ablation, we would recommend going forward and obtaining the all of the necessary authorization for the phlebectomy and the sclerotherapy as well.
Using the above assumptions, for two ablations we would also ask for two phlebectomies and four sclerotherapy authorizations; for four ablations, you would request four phlebectomies and eight sclerotherapy authorizations. It is usually much easier to obtain the authorizations for the attendant services up front than after you have initiated treatment.
One thing to remember is that authorizations are typically time sensitive. The authorization for some of these attendant services could expire before you are able to use them. If so, you can typically ask for the authorization termination date to be extended. If not, you can also just request a new authorization. As they have previously authorized the service, it tends to be very easy to obtain a new authorization.
If you never use an authorization, no problem. If you do not have an authorization and need one, big problem.
by AJ Riviezzo
When obtaining the authorization for the ablation, we also recommend obtaining the authorization for any additional services you routinely provide. Let us presuppose in your practice you average one phlebectomy for every two ablations and one to two medically necessary sclero procedures for every ablation. When obtaining the authorization for the ablation, we would recommend going forward and obtaining the all of the necessary authorization for the phlebectomy and the sclerotherapy as well.
Using the above assumptions, for two ablations we would also ask for two phlebectomies and four sclerotherapy authorizations; for four ablations, you would request four phlebectomies and eight sclerotherapy authorizations. It is usually much easier to obtain the authorizations for the attendant services up front than after you have initiated treatment.
One thing to remember is that authorizations are typically time sensitive. The authorization for some of these attendant services could expire before you are able to use them. If so, you can typically ask for the authorization termination date to be extended. If not, you can also just request a new authorization. As they have previously authorized the service, it tends to be very easy to obtain a new authorization.
If you never use an authorization, no problem. If you do not have an authorization and need one, big problem.
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