Re: Re; Resurfacing and which docs are using right codes

[Guest guest]

Dear " R " ,

As you and others probably know by now, there are certain comments on

this board that really upset me and that trigger a reaction. This is

one of those instances.

You have been grossly misinformed if you were told that other offices

are submitting requests using language that states " THR but

resurfacing if necessary " or similar language. That simply isn't the

way the process works. I have said this so many times including in

this discussion group but I'll repeat it once again: THE CODE IS

IRRELEVANT!!!! We, too, seek authorization using 27130 but we also

include language indicating that an investigational device has been

recommended by the surgeon.

This isn't rocket science. The issue is simply one of disclosure.

Either these offices are disclosing the FDA status of the device (ie,

" Investigational " )as required by their contracts with insurance

carriers or they are not. If all offices are, in fact, disclosing the

FDA status of the device while requesting authorization using the THR

code (27130), then there is simply NO WAY that one office would be

having a higher percentage of success than another. The only exception

would be if an office is located in a state in which a high percentage

of their patients are covered by an insurance plan that approves

resurfacing (e.g., Regence BC/BS in Washington and Oregon, Aetna) or

if that surgeon's office/hospital has reached a special agreement with

a local/regional plan such as an HMO to authorize resurfacing for

their beneficiaries. Unfortunately, Blue Cross of CA is the single

largest insurer in our state and it does not cover resurfacing even

though it did routinely prior to the Fall of 2001. By the way, many

BC/BS plans based in other states have authorized the surgery and in

this situation BC of CA make the payments to the hospital (and BS of

CA makes the payments to physicians) even though BC of CA doesn't

authorize the surgery for its own members.

Another example: It is common knowledge in the industry that surgeons'

offices participating in the ceramic-ceramic THR clinical trials DID

NOT disclose the investigational status of the device. Therefore,

there were few if any denials because the insurance carriers would

have no reason to deny the THR surgery absent the disclosure.

Please do not believe that other offices are " doing something right "

and that the JRI is " doing something wrong " when it comes to seeking

authorizations for surgery. I hate to be so blunt but if an office is

having no denials then it is no more complex than that they are simply

NOT disclosing that a clinical trial with an investigational device is

involved. These offices are not going to admit to their patients or

others that they engage in this practice.

Many months ago, someone on this board pondered that if an office

engages in fraudulent activity regarding obtaining authorization for

surgery (our hospital's attorneys are adamant that non-disclosure is

illegal), are they truthful in all other areas and interactions

involving their patients? It is a fair question and one that every

prospective patient has a right to ask.

Regards,

Chuck

JRI

> > > > Chris...

> > > >

> > > > If that's truly the way it works, and the insurance company

> > > > understands the same thing the doc does, and if everybody is

> > > playing

> > > > the same shell game by the same (mutually understood rules) I

> > have

> > > no

> > > > problem. If the doc writes something that SEEMS to comply

> with

> > an

> > > > insurance company coding, but is actually something else...I

> > still

> > > > gotta say...that's not telling the truth. And if CIGNA is

> > > rejecting

> > > > these more than it's accepting them at JRI...but paying as

> much

> > as

> > > > 75% for a BHR Belgian resurf, I have to ask some serious

> > > questions.

> > > > (But, I must be honest: many people have said I'm too rigid

> about

> > > > such things.)

> > > >

> > > > Whatever my issues might be...you seem to to doing quite

> > > well...and

> > > > that makes you an exemplar of what's possible, however we pay

> for

> > > it.

> > > >

> > > > All the best,

> > > > Alan