Modifier 80 Assistant Surgeon

dsg862

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I have one insurance company that keeps denying an assistant surgeon for a procedure that MCKesson says yes, medicare says yes and all other commercial insurance companies pay for without getting a preauthorization for the assist. surgeon. This company says their HMO (including all of it's various types of HMO) requires an auth across the board. When I ran a report to see what this company has done in the past year, I see that they pay 68% of the time without the auth and deny the rest. When I asked for their policy in writing it was denied to me. How can I fight this?
dsg862
 
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San Diego
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Hi,

I think you're going to need the assistance of the Rep assigned to your region of the HMO or perhaps your doctor can petition for payment to the Medical Director of the HMO. Without having obtained prior Auth for the Asst Surgeon, you're really at the mercy of the HMO. Also, in future cases, I would make sure that prior auth was obtained for both the Primary & Asst Surgeons - despite what other payors allow for.

Good Luck!!
 

sm9jack

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you can file an appeal. provide all of your documentation to support your reasoning. if this fail, you can always go to the commission.
 
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