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Patient admitted through ER, hence, cannot be held financially liable for out of network physician’s fees once inpatient treatment started, as she had “no choice” over which doctor would render surgical services.
Patient: “L.S.” Carrier: Empire BCBS
Date(s) of service: 9/20/2011 (first surgery) Dx: Uterine Leiomyosarcoma
CPT line items(# of procedures): 11 Total Claim(s) Amount:$ 112,381.86
Amount paid to provider:$ 112,381.86- (100%)
Note: Patient’s malignant cancer recurred metastatic one year post initial treatment, requiring second surgery by same physician.
Second date of service: 8/8/2012
Dx: malignant neoplasm liver/bile ducts and retroperitoneum CPT line items (# of procedures) 6
Total Claim amount : $ 62,861.92 (surgery)
$2,938.28 (Evaluation & Management- 10 day inpatient stay)
*Initial carrier decision – claim denied, resulting in zero reimbursement
Carrier denial reason: “Contractual – subscriber’s contract does not cover metastatic disease. (See BCBS denial letter attached dated 8/15/12)
Appeal/Re-submission date: 9/3/13 Claim settlement date: 9/18/13
Amount Paid:$ 62,861.92 (100% – surgery)
$2,938.28 (100% – E/M care)
To be provided
Patient: “T.S.” Carrier: Oxford
Date(s) of service: 1/25/2012
Dx: Intestinal Obstruction, Colon Cancer CPT line items(# of procedures): 8 Total Claim(s)
Amount:$ 29,979.52
Initial payment to provider:$ 12,780.84 paid on 3/1/2012
Case notes: patient admitted emergently
Carrier adjudication method:
1) Out of network provider – limited benefits
2) Zero paid on 4 of 8 codes, bundled as “inclusive to primary procedure” and/or part of surgical package
Appeal/Re-submission date: 4/5/2012 Signed settlement w/ carrier on 4/13/2012
Settlement Amount: 28,480.54 (95% of billed charges – zero patient responsibility)
SECOND SURGERY {same provider) – 9/26/2012
Second date of service: 9/26/2012 Dx: Colon Cancer, Liver metastasis CPT line items: 7
Total Claim amount:$ 47,906.37
Initial payment to provider:$ 24,781.50 issued on 10/29/2012
Carrier adjudication method:
1) Fees reimbursed at “reasonable and customary” rates
2) Multiple procedure rules, subsequent line items paid at 50% of” R & C”
3) Code bundling
*Initial carrier decision – Elective admission for surgery, services rendered by out of network provider, patient responsible for balance of $23,124.87
Appeal/Re-submission date: 1/15/2013
Appeal basis: Intra-operative consultation resulting in surgery
Claim settlement date: 2/12/2013
Amount Paid:$ 20,729.55
Total paid to provider:$45,511.05 (95% of billed charges, – zero patient responsibility
To be provided
Patient: “G.G”
Carrier: CoreSource (Employer Funded) Initial ER admit
Date(s) of service: 5/12/2012
Dx: Diverticulosis of small intestine, Intra-abdominal abscess CPT line items(# of procedures): 2
Total Claim(s) Amount:$ 16,585.66 Amount paid to provider:$ 14,367.00 (87%)
Note: – provider chose not to balance bill for remaining 13% in deductibles/co-ins
Second ER admit
Second dates of service: 7/13/2012- 7/28/2012 Dx: Renal Failure w/lesion of tubular necrosis CPT line items 16- (E&M codes for 16 day inpatient stay) Total Claim amount: $4,101.00
Amount paid to provider $3,925.00 (96%)
Third ELECTIVE admission for surgery
Date of service: 9/13/12
Total claim amount:$ 21,393.33
Initial payment to provider:$ 10,075.10 on 11/20/2012
Carrier adjudication method:
Claim processed as out of network – Elective surgery – covered at 70% Code bundling. Multiple procedure rules paid at 50% of “reasonable and customary”
Appeal/Re-submission date: 1/8/13
Contacted Employer’s Human Resources Dept. with patient’s permission.
Appeal Basis: elective surgery post ER surgery for treatment for same Dx {medical justification for same provider to render follow-up procedure due to exclusive medical/anatomical knowledge of the patient’s condition, {i.e. enterostomy closure and take down splenic flexure)
Claim settlement date: 3/1/2013 – (five months post date of service) Amount Paid : $ 10,952.15
Total paid to provider for ELECTIVE out of network surgery: $21,027.25 (98% of providers fee)
To be provided.
Patient: “N.P.”
Carrier: EMPIRE BCBS Date(s) of service: 5/1/2012 Pre-Op Dx: Acute Appendicitis
Post-Op Dx: Acute Appendicitis, Meckel’s Diverticulum
CPT line items(# of procedures): 2 surgical procedures, 2 E/M charges Total Claim(s) Amount:$ 18,945.03
**Initial amount paid to provider:$ 1,405.04 (7%) on 6/21/12
Carrier Adjudication method:
1) subscriber’s contract has limited emergency benefits, additional payment must be approved by patient’s employer.
2) Subsequent procedure (excision ofMeckel’s diverticulum) not reimbursable as “inclusive to primary procedure”
Appeal/Re-submission date: 7/12/12
**Second carrier payment:$ 1,356.55 (now 14% covered)
Carrier reason: “Upon review of patient’s contract, claim processed correctly and account is considered closed. Patient responsibility upon final determination” = $ 16,175.00
Note: With patient permission and cooperation, I contacted HR department at employer
Appeal/ potential litigation basis:
two separate incisions (further clarification available upon request) Employee coverage and basic ethical standards
**Final settlement date: 3/26/13 – approx. one year after date of service Amount Paid:$ 17,294.20 (94% of total billed)
Provider chose not to bill patient for deductible/co-insurance (7% remaining balance)
PATIENT TESTIMONIAL
“Angelo was amazingly helpful, in guiding us through the confusing and murky waters of negotiating with our insurance provider. Without his help, it would have been a significantly longer and more challenging road to recovery. It took over a year, but he helped us get full coverage as the claim was covered at 100% !”-Betsy P.
Elective sarcoma surgery, with obstruction
Patient: “J.M.”
Carrier: United HealthCare Date(s) of service: 1/16/2013
Dx: uteric obstruction, kidney dysfunction, uterine leiomyosarcoma CPT line items(# of procedures): 8
Total Claim(s) Amount: $99,518.05 Amount paid to provider: $73,453.73
Result:
Every procedure billed was reimbursed at highest allowable benefit per plan. Not a single code was denied or “bundled”.