If you have traditional Medicare, the vendor is required to notify the pt up front that Medicare is not expected to pay for the product/procedures, and the pt understands that they are responsible for costs associated with the product/procedure provided. That is called an Advance Beneficiary Notice of Non-coverage, https://www.medicare.gov/basics/your-medicare-rights/your-protections if the pt was not notified upfront and did not sign such a form. The pt is not required to pay for the products/services not covered and paid for.
However, since Medicare Part-C (Advantage) prgms are provided by for-profit private insurance companies, this policy & form may or may not apply. I guess that insurance companies are moving from using the prior authorization process to being able to deny care. To give the vendor a prior authorization approval upfront and then come back after the product/procedure was provided to “question” if the product/service was medically necessary and try to claw back the monies paid to the vendor or deny to pay the vendor.
ASCs see post-procedure payer clawbacks intensify
As scrutiny increases on payer prior authorizations, health plans are using a new tactic to disrupt provider cash flows: post-procedure clawbacks.
ASCs in some markets have noticed insurance companies scrutinizing even previously approved claims post-procedure and denying care or re-evaluating circumstances of the case to recover funds.
“All the insurance carriers are now hiring companies to look at a post-procedure type of prior authorization, or post-authorization,” said Adam Bruggeman, MD, a spine surgeon at San Antonio-based Texas Spine Care Center and chief medical officer of MPOWERHealth, during a June 21 panel at the 21st Annual Spine, Orthopedic & Pain Management-Driven ASC + The Future of Spine Conference in Chicago. “Essentially you’d perform the procedure and then after the procedure, using all the same data they asked for going into surgery, they’re now asking hospitals, surgery centers and doctors again to confirm that they really should have approved the surgery the first time and then they’re clawing back the money, or not paying the money as a result.”
To combat the clawbacks, Dr. Bruggeman’s team has identified the information payers ask for post-procedure and gathering it from physician offices before surgery.
Columbia (Mo.) Orthopaedic Group has seen similarly aggressive tactics by local payers and built a whole department focused on preauthorizations and post-surgery payer requests. The group spends hundreds of thousands of dollars per year to maintain the department, which is a heavy lift for an independent organization. But so far, the investment has paid off.
“Our physicians feel the pain in the clinic, but they haven’t felt it in their wallets yet because our departments are really, really good at making sure we get the money that’s theirs,” said Andrew Lovewell, CEO of Columbia Orthopaedic Group. “We have a lot of robust processes ahead of time where the doctors know the day before surgery exactly what codes are approved. They have to email if they do anything differently in the case. They have to tell us immediately or they face a penalty inside of our own group. We take both sides of it, not only to educate our providers but then go directly after the payers.”
Mr. Lovewell’s center does around 2,000 total joint replacements per year and a big payer has taken aim at the procedures.
“They’re going back and retro trying to deny implants we put in from six months ago. They’re doing a huge sweep,” said Mr. Lovewell. “They’ve hired a third party and then we’re spending money and time sending all these records back to them and they approve every single one of them. It’s just a nuisance headache.”
The payer requested almost 6,000 patient records on implants over a two-year period after approving everything upfront. Mr. Lovewell asked for an increase in rates because the business office will spend significant time pulling those records. He also threatened to go out of network and send those procedures back to the hospital.
“What I think we’re going to see, as more light gets focused on prior authorization, they’re going to shift to post-procedure techniques to try and extract the same amount of money and reduce the same payments,” said Dr. Bruggeman.
Filed under: General Problems
How can they possibly do this when THEY APPROVED IT IN THE FIRST PLACE?! The lengths people will go to claw back $ is mind-blowing!