Resolved OON Provider Performing Intraop Procedures

[JuliaS_81202]

A Plastics provider with my group is OON with most insurances. He’s frequently called to perform intraoperative closures on scheduled surgical cases by other providers of different specialty. All his claims are being denied for no auth, I’ve tried to submit medical records citing it was an intraop procedure, but the denials get held. Any advice on how to dispute this would really help. TIA!

 

[Lori]

How would you resolve a denial for no authorization?

If the denial reason was “no pre-authorization,” ask the plan to back-date one. If they will, resubmit the claim with a note including the new auth number. If they won't, appeal.

Best practices for reducing claims denied for prior authorization​

1. Appeal – then head back to the beginning. Make it part of your eligibility process to check whether or not prior notification is required for every visit, order, procedure, and referral.
2. Plan for denials. A certain number of denials will occur, regardless of how diligent you are on the front end. Planning for this takes the emotion out of the process—they’re inevitable, so expect it and budget the time and resources to resubmit the required medical documents to appeal them.
3. Double-check CPT codes. It’s critical for billers and physicians to work hand in hand to mitigate denials from having an incorrect procedural code on the prior authorization. For example, if a provider schedules a biopsy that doesn’t need prior approval but then excises a lesion (needs prior approval), the claim for the excision will likely be denied. There’s no penalty for authorizing a procedure and not completing it, so it’s better to err on the side of requesting authorization for all possible scenarios.
4. Take advantage of evidence-based clinical guidelines. Thorough documentation based on a respected clinical source is the best way to obtain preauthorization or appeal a denial. In addition to government sources such as AHRQ, it may be worth asking your most frequent payers what guidelines they use.
5. Clearly document any deviation from evidence-based guidelines. For example, if a provider plans to perform a sigmoidoscopy on a 45-year-old patient, it’s critical to include the fact that the patient’s family history includes colon cancer in a first-degree relative at age 40 on the precertification request.

Never be afraid to appeal a payer’s decision. Phone calls to the health plan’s medical director, while time-consuming, can be extremely effective in changing outcomes.

For situations in which one surgeon performs the opening and closing of a surgery and another physician performs the definitive portion of the procedure, both physicians should report the same CPT codes, and appropriately append either modifier -62 or modifier -66.

62 -Two Surgeons
66- Surgical Team




Please see these free resource threads:

Resource - Denials

Review Reason Codes and Statements CMS contractors medically review some claims (and prior authorizations) to ensure that payment is billed (or authorization requested) only for services that meet all Medicare rules. If the review results in a denied/non-affirmed decision, the review contractor...

www.cco.community

Resource - CPT Modifiers

CCO Video Modifiers Made Easy: FREE CCO TOOL: https://www.cco.us/cpt-modifier-decision-grid-tool/ 22- Increased Procedural Services 23- Unusual Anesthesia 24- Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative...

www.cco.community