Assistant Surgeon claim denial: considered inclusive ...

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In GYN surgery, the primary surgeon did multiple procedures. The assistant surgeon assisted with only one of those procedures. The procedure that had the assistant was considered inclusive of the other services done by the primary surgeon. Does the assistant surgeon have any standing for appeal? I have no administration over the claims or billing of the primary surgeon. The assistant surgeon is reaching out to me to see if there is anything he can do to get paid.
 

thomas7331

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There's no logic I can see for denying an assistant charge as inclusive to a surgeon's charge in a situation like this, but payers are often illogical so it's no surprise. Your standing in an appeal will depend on the payer's policies, how clear your provider's documentation is, how persuasive an appeal letter you can write, and perhaps most importantly, a certain amount of luck in being able to have the appeal reviewed by someone who understands it. But as long as the procedure is one for which an assistant is usually allowed and the documentation supports the charges, then there is no reason I can see that this shouldn't be paid.
 

mitchellde

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This is just a thought here.... call it thinking out loud... Logically if the procedure in question is comprehensive or a component to another procedure, and If the assistant was needed on the second procedure, then wouldn't it logically follow that the assistant actually assisted on the one procedure that was billed? I mean being that those are components of the other service.
 
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