First Appeal - Additional coverage denied for bilateral...

[mustang4172]

I had bilateral resurfacing performed by Dr. Su.  The amount he was reimbursed is nowhere near his fee.  I made a first appeal to BCBS but was denied any increase in coverage.  I'm well aware of the out-of-network benefits that I can expect, but I don't understand how the Maximum Allowable Amount can be so much lower than the surgeon's fee.  In the letter I received from BCBS Appeals, they stated that the National Medicare Fee schedule for procedure code 27130 (arthroplasty of the hip) is $1445.58.  When this rate is multiplied by 315%, a Maximum Allowable Amount of $4553.57 is obtained.   Does anyone know how the $1445.58 number is determined?  It is very puzzling to me that $1445.58 is the number they're starting with for such a major surgical procedure.

I've been informed that I can request a voluntary second level appeal.  My argument will be that I chose Dr. Su because he is one of the top surgeons to perform this procedure.  Perhaps I could have used a surgeon in my network (something I never really considered), but I wanted to be in the most capable hands to avoid any future complications.

Any other Dr. Su patients out there that have been successful in gettng more coverage after appeal? 

Any feedback is appreciated.
 

[kimberly52]

Hi Mustang,

Oh you asked that dreaded question about how they arrived at the number.  It is a very complex system which has been in place for many years now.

Medicare uses the RBRVS or resource-based relative value scale.  For each procedure performed an RBRVS is assigned and takes into account the actual physician work, expense of the practice, and malpractice expense. These expenses are not physician specific, but are general expenses determined by HCFA, Healthcare Financing Administration or CMS.

The RBRVS is adjusted by the value of the procedures for various geographic regions. Say the same work performed in D.C. would have a higher value as if it were performed in S.C. where the cost of living is lower in S.C. vs D.C.  A conversion factor that is adjusted annually is applied to the RBRVS to arrive at the amount of payment for the procedure.

What it boils down to is that Medicare's determination of the value of a procedure code is the Holy Grail for reimbursement throughout our healthcare system.  Major insurance carriers base their reimbursement on the rates that Medicare sets. As I noted, the conversion factor is updated annually and therefore drives the change in the value of the procedure codes annually too.  Medicare publishes the adjusted rates annually.

The fact that the Medicare rates are the Holy Grail of reimbursement is one of the many flaws in our healthcare system.  The Medicare rates are extreemly low in comparison to the actual cost of operating a practice and when an insurance company negotiates their contracted rates based on the Medicare rates, the insurance companies normally are getting away with grand theft!  But they do get away with it because they hide behind what Medicare has established.

Sorry if I go on and on. I used to have to deal with reimbursement in my former job and it still hits a nerve with me.

I hope that I have explained it in a nutshell. There is so much more to it though.

Kim

[mustang4172]

Thanks for the detailed explanation Kim!  I figured there was some type of scale used.  Still amazes me that the starting number is so low.

Thanks again, appreciate your feedback.

[kimberly52]

Yes it is low.  But then again it is our Government that establishes that number and their objective is to cut their reimbursement costs.  Unfortunately it sets the precedence for our insurance giants to improve their bottom line.  :(