Wiki Not medically necessary/ insurance

[SUN1633]

Hi,
Our practice does a lot of excisions. Sometimes we come across one for something such as a keloid that patient is requesting removal basically because they don't like it. There is no mention of pain, bleeding, irritation etc. They are adamant that we file removal to their insurance . How would your practice best handle this situation?
Thanks in advance.

 

[thranowski]

Hi,
Our practice does a lot of excisions. Sometimes we come across one for something such as a keloid that patient is requesting removal basically because they don't like it. There is no mention of pain, bleeding, irritation etc. They are adamant that we file removal to their insurance . How would your practice best handle this situation?
Thanks in advance.

Before the procedure is performed, I would call their insurance to ask if it's covered. If it isn't, they have to pay cash up front. At the very least I would have them sign an ABN, but to collect money after the fact, statistically the risk of not getting paid by the patient is super high.

 

[thomas7331]

My recommendation is: follow the ABN process for Medicare patients, and for non-Medicare payers to follow a similar process - in other words, have the patient sign a waiver to indicate that they understand that the provider believes this is a non-covered service which the payer may not cover, which they will pay in full up front, and that the payment will be refunded if and only if the payer actually reimburses the provider. Have your providers document that this is a cosmetic procedure and file the claim with primary diagnosis code Z41.1 to indicate this clearly to the payer so that you aren't accused of falsely submitting medically unnecessary services to a payer.