Wiki Humana Medicare Advantage-surgical assistants

[AMADDOX]

I do billing in Texas for LSA's (licensed surgical assistants) who are able to file independently to many insurances and get paid. We have always filed and received payment from Humana in the past. Even the Medicare Replacment plans would send us agreements to sign stating we accept assignment and would only bill their
members the allowed amounts. Just today I started getting refund requests for the entire paid amounts for all of these claims. They are now stating that per the CMS guidelines LSA's are not a payable provider. Anyone else having this happen? Someone of these claims are 1-1 1/2 years old. Any advise on ways to fight this? Humana clearly knew the providers credentials, as well as all the claims had the appropriate AS modifier. I'm at a loss.

 

[OCD_coder]

This is a very interesting question, thanks for sharing.

Going from my education standpoint, I was taught that a MAC's or contractors cannot override CMS rules; this would apply to managed MCR plans I would think. Meaning they cannot make the rules "looser" than what CMS states. But a contractor can make the rules more restrictive. So going on that theory, I would hesitate to say billing for a LSA would be allowed given that CMS only recognizes a physician, PA, NP or CNS.

CMS Assistant Surgery Guidelines:
Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS).

It sound like they are correcting one of their oversites, but please don't take my word as gospel.