Insurance approved prior auth but denied procedure!!

[alex30103]

I had eyelid surgery which consisted Ptosis repair (rising up upper muscle) Blepharoplasty (removal of extra skin that is holding over my eyes). They are usually done together as it’s the same incision. Both were to fix impaired vision due to my eyelids obstructing my field of vision. Surgeon sent PA for both procedures and both were approved.

When surgery was scheduled I was told that only Ptosis repair would be performed and Blepharoplasty would be done at another time because insurance would only cover one at a time. I called insurance and spoke to a manager, and she said that both procedures will be covered if done together as they are both in the prior authorization. So she called the doctors office and explained and the doctors office agreed to schedule the surgery for both procedures at the same time. However, they did make me sign a document saying that both procedures may not be covered, and I would be responsible for the balance, if they are not covered.

Now, to my surprise, only the ptosis repair was covered, and the other was bundled into the procedure as they are mutually exclusive. So technically the insurance paid for both procedures as part of one procedure. And the doctor’s office wants me to pay the difference (over 2k). The explanation of benefits says that I have zero responsibility.

On one side, the doctors office tells me that they made me aware that it will not be covered and I signed the document saying that I will pay for it. And on the other side, I have the insurance saying that they did pay for both procedures as both procedures codes are in the payment, but they say that if I signed a document that is between the Doctor and I.

What should I do in this situation? Can I argue that the procedure was technically paid for? Does the insurance have any obligation to prohibit them from charging me when I have 0 responsibility?

 

[rousemark]

I had eyelid surgery which consisted Ptosis repair (rising up upper muscle) Blepharoplasty (removal of extra skin that is holding over my eyes). They are usually done together as it’s the same incision. Both were to fix impaired vision due to my eyelids obstructing my field of vision. Surgeon sent PA for both procedures and both were approved.

When surgery was scheduled I was told that only Ptosis repair would be performed and Blepharoplasty would be done at another time because insurance would only cover one at a time. I called insurance and spoke to a manager, and she said that both procedures will be covered if done together as they are both in the prior authorization. So she called the doctors office and explained and the doctors office agreed to schedule the surgery for both procedures at the same time. However, they did make me sign a document saying that both procedures may not be covered, and I would be responsible for the balance, if they are not covered.

Now, to my surprise, only the ptosis repair was covered, and the other was bundled into the procedure as they are mutually exclusive. So technically the insurance paid for both procedures as part of one procedure. And the doctor’s office wants me to pay the difference (over 2k). The explanation of benefits says that I have zero responsibility.

On one side, the doctors office tells me that they made me aware that it will not be covered and I signed the document saying that I will pay for it. And on the other side, I have the insurance saying that they did pay for both procedures as both procedures codes are in the payment, but they say that if I signed a document that is between the Doctor and I.

What should I do in this situation? Can I argue that the procedure was technically paid for? Does the insurance have any obligation to prohibit them from charging me when I have 0 responsibility?

Many insurance plans state that if more than one procedure is performed through one incision they will only pay for one.

 

[alex30103]

Many insurance plans state that if more than one procedure is performed through one incision they will only pay for one.

What if there was a prior authorization for both procedures? Wouldn’t they have denied it?

 

[somarco]

What kind of insurance do you have? Employer group health (PPO or HMO), ACA, Medicare?

Ptosis is the diagnosis (ICD10 coding), blepharoplasty is the procedure to correct ptosis (CPT4 coding). Blepharoplasty should be covered if your vision is impaired by X% . . . in other words, correcting the condition is considered medically necessary, not cosmetic.

https://www.icd10data.com/ICD10CM/Codes/H00-H59/H00-H05/H02-/H02.409

A financial responsibility document is not uncommon. If the submitted claim is properly coded. These are signed in advance of treatment.

Your post makes it seem as if the procedure has been completed and the EOB indicates the claim has been paid in full. But you also appear to say the surgeon is balance billing you. Or is the bill from another provider, the facility or anesthesiologist?

If all providers are in network, their managed care contract should state they agree to accept the insurance reimbursement as paid in full.

Clarification, please.

 

[alex30103]

What kind of insurance do you have? Employer group health (PPO or HMO), ACA, Medicare?

Ptosis is the diagnosis (ICD10 coding), blepharoplasty is the procedure to correct ptosis (CPT4 coding). Blepharoplasty should be covered if your vision is impaired by X% . . . in other words, correcting the condition is considered medically necessary, not cosmetic.

A financial responsibility document is not uncommon. If the submitted claim is properly coded. These are signed in advance of treatment.

Your post makes it seem as if the procedure has been completed and the EOB indicates the claim has been paid in full. But you also appear to say the surgeon is balance billing you. Or is the bill from another provider, the facility or anesthesiologist?

If all providers are in network, their managed care contract should state they agree to accept the insurance reimbursement as paid in full.

Clarification, please.

It’s an ACA plan. Ptosis is the diagnosis, and two “procedures” were used to repair the ptosis.

The first one is Blepharoptosis/lid retraction is explicitly where the eyelid is lifted up (no skin is removed). The muscle is tightened so that the eyelid can lift and open more adequately. This is considered the most invasive because it manipulates the eyelid muscle. Proc code 67904.

The second one is Blepharoplasty, which is where excess skin is removed. In my case, the skin is hooded and also obstructing my vision. If this is done alone, the height of the eyelid does not change. This is done using the same incision as in blepharoptosis. Proc code 15823.

Yes, the EOB says I owe 0. But procedure code 15823 says denied because “this service is part of a procedure that has already been billed”. In other words it was bundled into the other procedure. Please see the EOB attached. The surgeon is billing be for the procedure that was not paid and he is in network. But the insurance said they can bill me since we have an agreement.

 

[somarco]

Note below the EOB indicates the claim was already billed (and presumably paid). I don's see any CPT codes on the EOB which should indicate which procedures were covered, which denied.

If the claim is denied because the provider has been paid I don't believe you are responsible, but ACA is not my forte.



67904 is a broad code used for "repair eyelid defect", while 15823 is for "revision of upper eyelid" and is commonly a secondary surgical procedure which is performed to correct any complications that have arisen or to improve the results of a previous eyelid surgery.


It is possible the provider is attempting to upcharge you and the carrier, or the procedure was miscoded from the start.

What does your agent say?

You may have to use the appeal process with your carrier if you want relief.