2012 ASOPA Breakout Course
The Challenges and Pearls of Surgical
Billing and Appeals for the First Assistant
David Bartczak, OPA-C, LSA, CSA, OTC
Affiliations and Background
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Mederi Services, LLC (owner)
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TCOPA – Past President, VP, Treasurer
lNBCOPA – Parliamentarian / CME
Committee
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18 yrs experience in billing and coding that
started while in the military
Understand the Difference
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Not all assistants are the same
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Many states have different laws that apply
to how an “assistant” can be used and
billed
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Know your local laws
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Some states do license assistant that are
non-MD and non- PA-C, ie LSA, RSA
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As a general rule, if you can get
credentialed to assistant then you should be
able to bill for it.
Introduction
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Discuss current techniques in billing
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Discuss current challenges for billing an assistant
that is employed and independent
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Appeal or not to appeal and why
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What is that EOB really saying?
Current Techniques in Billing
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CPT Modifier - AS represents a non MD First
Assistant at surgery.
l CPT modifier -80 represents assistant at surgery by
another physician.
l CPT modifier -81 represents minimal assistant at surgery
by another physician. This assistant at surgery is providing minimal assistance to the primary surgeon. This modifier is not intended for use by non-physician assistants (e.g., RN, PA, OPA-C, LSA).
l CPT modifier -82 represents assistant at surgery by
another physician when a qualified resident surgeon is not available to assist the primary surgeon.
How Much to Bill for Services of an employed OPA-C or assistant
l Recommend “Minimum” of 50%; easier to calculate.
Some Assistants do 75-100%
l Use your NPI and the Practice TID
l Most insurance companies now pay based on the TID
number and if it is in network then you will be also
l BCBS will pay standard 14 % of allowed amounts for
most cases at in-network rate
l Insurance companies out network rates are paid at a % of
what is billed instead % of what is allowed
l Sample – Joint Replacement charge of 6000 for the
Surgeon, 3000 (50%) for the OPA-C. Paid at 35% equals $1050 or if we billed $1500 (25% as some recommend) then we would be paid only $525 which is a $980 loss.
How Much to Bill for Services of an Independent OPA-C or assistant
l Use your NPI, your company Type 2 NPI and your company EIN/
TID
l There is usually no standard methodology for Out of Network
payments from most private insurance but some HMOs pay at the same rates for either
l It seems that Insurance companies out network rates are paid at a % of
what is billed instead % of what is allowed
l Recommend 3x Medicare “allowed” for non-paying cases and 4 ½ -
6x Medicare “allowed” amounts, these rates generally line up with the middle and high rates of the Physician Fee Schedule guide
Type of Denial Wording Seen
l Member Plans Covers Charges that are reasonable and appropriate asdetermined by "insurance Company".
– Means they don’t want to pay any more.
l This has been paid following "Insurance Companies" guidelines for
multiple procedures and services performed on the same date of Service.
– They are reducing payment because of multiple procedure (100 of 1st, 50% of 2nd and
25% for all others)
l Reimbursement for surgery includes elective services of assistant.
– Not saying one isn’t needed, just that they aren’t paying for them
l The prevailing reimbursement for this surgery includes any elective
services of a surgeon or nurse assisting the operating surgeon. The charge for the assistant surgeon, co-surgeon, or surgical team is not covered under the members plan.
Type of Denial Wording Seen (cont)
l Your Plan Does Not Permit Payment for this Type of Provider
– Yes you should be paid but this cheap policy / company won’t be doing it J
l We are unable to locate a valid provider number on our system (BCBS)
– Their way of denying claim without discrimiating agaisnt you since they will not “validate” certain providers
l If you don't agree with our assessment, you may appeal on the member's behalf
with signed authorization from the member. (UHC, BCBS, Cigna)
– You must get members authorization and send in with appeal before it can be considered. There is generally a time limit to appeal.
l Services by a provider who does not participate with Aetna are not covered
unless the services of the on participating provider are pre certified.
– There is no way for non-MD to be able to precert since they only precert hospitals and MD for surgery
l Charge exceeds the priced amount for this service. Services provided by a non-
participating provider. Patient is responsible for charges over the priced amount. (BCBS)
– Means they do not agree with how much you charged and they want you to think you charged too much .
Appeal or Not to Appeal and Why?
l Plan to appeal everything if needed
l Make your appeals look professional and quote laws /
statutes when possible to help
l Know whether claim should have been paid to begin with
l Identify amounts paid as “fair”, generally over 500 per
case
l Remember, “pigs get fat and hogs get slaughtered”
Appeals to Use for Insurance Companies
l Case Law supports refund requests by insurance companies
(Appeal for refund requests)
l Most companies may dismiss if you appeal a refund three
times (Cigna more persistent that most)
l If they take money back from future claim then just consider it
an interest free loan
l Appeal ALL secondary insurance companies. Most will deny
on first claim. (Appeal for them to act as primary)
l Appeal everything for medical necessity once if not paid l Appeal if not paid at 100% of billed to see if they are paying in
network or out of network. (Underpayment) Careful with Cigna and Medicare replacements
l Only send the information they request
Trends for payments to assistants
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Trends of insurance companies is either pay
everyone as in network or no benefits allowed for
out of network
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Have seen increase in Aetna considering services
with surgeons payments or no payment unless you
meet the “definition of a physician” or Needed pre
cert
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Cigna polices starting to deny non license providers
including LSAs, but appeals do sometimes work and
see a lot of negotiated rates being offered
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Have seen a trend in the last 24 months that if the
practice TID is in network then the assistant will be
considered In-Network
Trends for payments to assistants (cont)
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Plan appeals if paid as in network, but realize
that if you shouldn’t have been paid that it may
bring attention to a claim that you don’t want.
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Have seen increase in “Request for Refunds”
but in the last 8 years I have never had any
returned when appeal is done.
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Have seen more patient’s with no Out of
Network benefits
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Partial knee replacements – “assistants not
How Much Can an OPA-C Get
Reimbursed for Assisting at Surgery
Private Pay Insurance (Primary)–
l BCBS
– C-Spine with hardware – Billed 15K – paid $3600 (CSA) (24%) – ACL Recon –Billed 2900 – paid $2900 (CFA) (100%)
– Foot Nerve Decompressino – Billed 5900 – paid $5900 (CSA) (100%) – THA – Billed 6000 – paid $4900 (LSA) (82%)
– THA – Billed 6000 – paid $5500 (OPA-C) (92%) – Breast recon – billed 9400 – paid $5000 (LSA) (53%)
l Aetna
– C-spine with hardware – Billed 11.4K – paid $6300 (CSA) (55%) – TKA – Billed 5800 – paid $3700 (OPA-C) (64%) Secondary
– Foot Nerve Decompressino – Billed 6400 – paid $6400 (CSA) (100%)
l Paid on appeal - initially paid $43
How Much Can an OPA-C Get Reimbursed
for Assisting at Surgery (cont)
Private Pay Insurance –
l UHC - This year has been the best payer!!
– THA– Billed 6800 – paid $6800 (OPA-C) (100%)
– Shoulder (RTC, Decomp) – Billed 11.3K – $7900 (OPA-C) (70%) – TKA – Billed 6000 – paid $4800 (LSA) (80%)
What Does the Future Hold for Assistants
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Obama Care
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License vs Certifications
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OPA-C School
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In Network vs Out of Network
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Employed vs Independent
Alternative to Standard Office
Settings for Employed Assistants
l Think about how to bring in extra revenue or reduce costs for your practice.l The idea is to increase the revenue and not changing the work relationship or duties l Become independent without changing your current situation
– Stay in the office with a reduced salary (i.e 50%) and continue all current duties – Bill surgeries independently of the surgeon with your own company
– Bill as an out of network provider
– Generally better to use outside biller instead of office billers since they do not know or understand appeals
– Saves the surgeon/company money by reduction in salary plus reductions of the amount of taxes they would be paying on your behalf (+/- 15-30% of your salary)
l Surgeon / company would start a separate company that would hire you at a “salary”
– Stay at current salary (hopefully more) with the same duties – Bill surgeries as an out of network company / assistant
– Also better to use outside billing company for same reasons as above
– Out of network billing generally pays much better than in network and this income would be filtered back to the surgeon / company
Summary
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OPA-C’s can be reimbursed by private
insurance
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There is legislation to support assistants,
LSA
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There is Case Law to help with appeals
lOPA-C’s and assistants can be reimbursed
by secondary insurance
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OPA-C’s can be profitable to a
Orthopaedic Practice.
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Independent Assistants can be very
profitable but not consistent.
Where to Get More Information
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TCOPA Website (tcopa.org)
lMederi Services Website
mederiservices.com
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CPT / ICD 9 Book
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American College of Surgeons Survey
lCase Law
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