02/27/2014    Joseph Borreggine, DPM

BC BS Wants Their Money Back (Joseph Borreggine, DPM)

Here's a follow-up to the matter regarding BC/BS
wanting their money back for a surgical procedure
they deemed an "investigational or experimental
procedure." I was under the impression after my
conversation during a requested peer-to-peer
interview with the DPM who initially reviewed the
case that my claim should have "no problem being
paid" if I just resubmitted a "corrected or
addendum" operative report to why a metallic
implant had to be used during a joint salvage
arthroplasty of the 1st MPJ utilizing CPT codes
28111 and 28126.

I did just as he requested and the union insurance
plan with BC/BS as its TPA stated that all claims
paid past, present and future will not be paid and
monies paid already will be recouped or must be
refunded by my office. The peer DPM who reviewed
this case initially opined that since a metallic
implant was used it was deemed experimental and
under investigation and hence would not be
reimbursed for services past, present, or in the
future pertaining to these patient's insurance
claims.

The union insurance plan stated in their
correspondence that I have 180 days to appeal this
matter. Regardless, they have already recouped all
in-office and outpatient claims paid and have
denied all post-op claims to date. Further,
investigation by the patient has revealed that a
pre-authorization for these services was not
obtained pre-operatively. An itemized bill from
the hospital where the surgery was performed
revealed that a metallic implant was used during
the procedure and therefore triggered the post-
payment review.

If anyone has a similar situation as this, your
advice and/or assistance in this matter would
appreciated. Since I am a member of the OPEIU
(Office of Professional Employees International
Union) through my state association, I have
contacted a union representative in our profession
who is providing potential help to resolve this
matter.

Joseph Borreggine, DPM, Charleston, IL,
footfixr@consolidated.net

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