According to Anesthesia Business Consultants, Health Plans Tighten Up On Anesthesiologists

JACKSON, Mich.--(BUSINESS WIRE)-- Anesthesia Business Consultants (ABC) publishes weekly articles on timely topics pertaining to anesthesia practice. The following is an excerpt from this week’s electronic mailing. To sign up to receive these eAlerts, or to view the following article in full, please go to:

Health insurers are invoking various mechanisms to protect their bottom line, including making it more expensive for beneficiaries to choose teaching and other high-cost hospitals. Insurance companies have also raised patient copayments in order to keep premiums deceptively level.

Filing Claims

CIGNA has reduced the time to file claims for medical services, announcing that “claims submitted to CIGNA on and after August 1, 2011 must be for services that were rendered within 90 days of the claim submission date in order to be considered for payment.”

In some instances it is impossible to complete the paperwork within 90 days. It can be difficult to ascertain just who the patient’s health insurer might be – the hospital information may be wrong; the patient may not respond to requests for the insurer name.

Payments That May Not Comply With the Contract

Always know what is in your payer contracts. The health plans may offer changes that seem innocuous or are easily overlooked at renewal time, or simply through mid-term policy announcements. More than ever, it is critical to look at the entire proffered contract and not just at the dollar conversion factor.

During the contract term, remittances may come up short against expected payments for reasons such as:

  • using multiple-procedure discount algorithms for add-on codes,
  • rejecting visit codes appended with a 25 modifier when billed with a procedure or surgical code, and
  • denying codes submitted with 59 modifiers.

Anesthesia-specific modifier problems have arisen repeatedly. The Medicare medical direction/personal performance/teaching modifiers can offer a pretext to cut payment. One insurer simply assumed that every claim for anesthesiologists’ services was in effect a modifier QK (medical direction) case and cut the allowed amount by 50 percent.

Note, too, the increasingly stringent policies designed to constrain spending on pain management. Pre-authorization is creeping back in, both explicitly and as medical necessity policies for which the pain physician can seek a determination from the health plan’s medical director.

Recall the successful New York prosecution of United Healthcare for using a rigged claims database: whatever the payer contends is the usual, customary and reasonable (UCR) charge may be demonstrably erroneous. “Anesthesia exceptionalism” has made it easy for payers to misunderstand anesthesia’s typical payment methodology. Many groups have been able to have payments adjusted by showing that the payer UCR data is wrong.

About Anesthesia Business Consultants

ABC, established in 1979, is one of the largest billing and practice management companies dedicated to the complex and intricate specialty of anesthesia and pain management. It is both an American Society of Anesthesiologists Practice Management Supporter, and an Anesthesia Quality Institute Preferred Vendor. ABC employs industry leaders, operates under proven efficient processes, and utilizes technology advances to easily adapt to the ever-changing regulatory environment.

If you would like more information about this topic, please go to [email protected]


Anesthesia Business Consultants
Tony Mira, 517-787-6440
[email protected]

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