Wiki Balance Billing

[TJAlexander]

I have been fighting with UHC since January regarding a back brace (L0650) dispensed to a patient. The patient signed for and received the brace then UHC denied for 'not medically necessary'. We've been going back and forth regarding documentation. The most recent appeal was sent in October 2020 citing LCD L33790. We then received a letter offering peer to peer to which the UHC Medical Director advised that she wouldn't determine the brace as not medically necessary but that we 'could have' used more conservative methods first. In the interim, I received another piece of correspondence from UHC saying our appeals have been exhausted and that we need the patient to sign off on any further appeals. Of course, the patient will not respond to any phone calls or emails.

Here's an excerpt of our latest appeal:
"We do not believe the denial is justified. According to your published Coverage Determination Guideline for DME dated 9/1/2020, “UnitedHealthcare has adopted the requirements and intent of the National Correct Coding Initiative. The Centers for Medicare & Medicaid Services (CMS) has contracted with Palmetto to manage Pricing, Data and Coding (PDAC) for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).” CMS LCD ID L33790 includes L0650 as “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…” and it is covered for one of the following indications:
To reduce pain by restricting mobility of the trunk; or

To facilitate healing following an injury to the spine or related soft tissue; or

To facilitate healing following a surgical procedure on the spine or related soft tissue; or

To otherwise support weak spinal muscles and/or a deformed spine.
is a 17-year-old male who presented with back pain x2-3 months. He experienced pain with motion and tenderness of the transverse process and para spinal region at L4. He was diagnosed with Spondylolisthesis. According to the American Academy of Orthopedic Surgeons, bracing is recommended with this diagnosis to limit movement and provide an opportunity for healing."

At this point, my provider began to insist that we bill the patient for the full cost of the brace and was deaf to my explanations of contractual obligations. I really don't know what to do. Georgia passed a law in July making balance billing illegal, however, my provider says that since the denial is without merit that we are within our rights to bill the patient.

 

[SharonCollachi]

You might want to take the patient's name out of there.

And a denial isn't balance billing.

 

[TJAlexander]

Thank you. I didn't see that the redaction in my word processing program didn't save. I haven't been doing this for very long but I was under the impression that being a contracted provider indicated that we were required to take a write-off when directed by the insurance carrier. If the brace was denied as CO-50, doesn't the CO mean that we are contractually obligated to take the write-off?

 

[csperoni]

You are prohibited from billing the patient in this scenario. But the reasoning has nothing to do with balance billing laws. It is your signed contract with the payor. Even if you believe the denial is without merit and the insurance is incorrect and unreasonable, that does not mean you may bill the patient.

For example, I'm sure we've all had the scenario where you billed the insurance timely, but they didn't receive it, process it, it got lost, etc. If after appeal, the insurance still will not pay, you may not bill the patient. You agreed to the insurance policies during contracting. Your only possible recourse here is with the insurance. Sometimes it helps to have the patient involved in the appeal process, but doesn't sound likely in this situation since the patient is not responding.

 

[TJAlexander]

I have to admit that I'm at my wit's end. Every time I have a discussion with my provider that he doesn't like the answer to, he talks over me as if I don't know what I'm talking about.

 

[SharonCollachi]

Does your state have any recourse at the state level? Here in California, after you exhaust appeals with the insurance company, you can send it to the state for an independent review, which is a binding decision. What exactly does their denial say, since their coverage guidelines look like it should be covered.