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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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