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Re: GEN: How do insurance carriers do this? (long) From: art fougner, md (evsono@pipeline.com) Sat Feb 26 16:09:05 2005 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: art fougner, md: "Re: Wrongful Death Suit Allowed Over Embryo" Previous message: Garry E. Siegel, M.D.: "GEN: How do insurance carriers do this? (long)" In reply to: Garry E. Siegel, M.D.: "GEN: How do insurance carriers do this? (long)" Next in thread: R. Daniel Braun: "Re: GEN: How do insurance carriers do this? (long)" Garry they don't have to since the first go round of submissions are often rejected out of hand - inertia is their most powerful tool. art At Sat, 26 Feb 2005, Garry E. Siegel, M.D. wrote: > >A discussion with a patient whose infertility is non-covered leads to >this long diatribe I've often wondered. Any thoughts welcome. > >The broad topic is how to insurers review claims and decide which are >paid automatically (i.e. probably no human input) and which are >reviewed. > >For instance: > >Mid level office visit, dx. endometriosis > >I would think this is paid without review, as the CPT and ICD-9 jive, >AND it is not an expensive amount. > >Now, what about: > >TAH, dx. Fibroids > >I would think that this is another slam dunk, but maybe the PROCEDURE or >the AMOUNT merit automatic review. > >So. . . > >If I bill a laparoscopy for a yeast infection, does the mismatch of >diagnosis/CPT generate a red flag? Or, does every surgery get reviewed? >Or, does any CPT that is paid over a certain dollar amount get reviewed? > >So. . . > >If I tried to bill a lapscope done in reality for infertility, but used >Pelvic Pain as the diagnosis, would the carrier catch it? Now, realize >I'm not doing this (unless she has documented pelvic pain). Also, if >the patient has previously had CPTs billed that are obvious, i.e. an >HSG, do they know? > >As an aside, someone on Clomid with oligoovulation can be billed for >office visits under "irreguar menses," I suppose, but if the carrier >sees a bill from the pharmacy for Clomid, do they figure it out? > >Whew! > >Garry > >-- >Garry E. Siegel, M.D. >Private Practice >Roswell, GA > -- art fougner, md "If you don't know where you are going, you will wind up somewhere else." Lawrence Peter Berra Next message: art fougner, md: "Re: Wrongful Death Suit Allowed Over Embryo" Previous message: Garry E. Siegel, M.D.: "GEN: How do insurance carriers do this? (long)" In reply to: Garry E. Siegel, M.D.: "GEN: How do insurance carriers do this? (long)" Next in thread: R. Daniel Braun: "Re: GEN: How do insurance carriers do this? (long)"

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