BCBS Medical Necessity denials

JAMETH345

Networker
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55
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Our office is Out of Network with BCBS. When we submit claims for Radio Frequency Abalations, often they are denied for Medical Necessity. There are a number of guidelines that need to be met to show medical necessity - 3 months of conservative therapy, previous Medial Branch Block has reduced pain by 50% or more, pain is not radicular, etc. The problem is that when I call to find out the specific reason for the denial, which guideline is not being met, they never give me an answer, other than the claim was denied correctly. And they absolutely will not put a supervisor on the line to resolve the issue. When I insist on a supervisor, they put me on hold, and leave me there, and after 30 minutes the call drops. It's hard to submit an effective appeal letter when you don't know the specific reason for the denial. Any suggestions for resolving this?



John Methgen, BS, CPC-A, CPB
 

thomas7331

True Blue
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3,133
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This is something I've run into frequently with payers and was usually able to resolve by getting a network representative involved, but that was when we were contracted with the payer. If you are out of network or don't have a rep available to go to, it's not a very pleasant option but I think your best bet is to make what you'd consider a reasonable effort to appeal the denial and if it doesn't work then bill the patient to get them involved (or contact them to let them know they will be responsible if it's not paid). Payers are going to be more responsive to an unhappy member than they are to a provider with whom they have no contract or relationship.
 

JAMETH345

Networker
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I appreciate the response. Often our patients don't want to get involved. Being out of network, often BCBS will send the payments to the patients, rather than to us, so there's two parts to my job: First, getting BCBS to pay, then trying to collect from the patients. Much of the time they don't return my calls, or respond to my letters.




John Methgen, BS, CPC-A, CPB
 
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252
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Albany
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I encounter this with BC and other payors as well. I have to appeal them with the documentation and point out to them that all the guidelines were met. It is a huge pain but most of the time they overturn their denials. Just make sure you are following the guidelines.

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management
 

JCaillouet

Networker
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As others have stated:

Your first best bet is to provide a Medical Necessity appeal with appropriate documentation. Usually you'll have a first or second level denial before you can make the remark that you applied a 'reasonable' amount of time to the denial to get it paid. A bill to the patient or a notification in your front office for all carriers that you're Out of Network for that they will be liable for any denials and to encourage the patient to reach out to the carrier.

That's the best which can be offered. Good luck.

Joshua Caillouet, CPC, CASCC, Professional.
RCM Lead - Senior Associate
Hexaware Technologies.
 
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