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BCBSIL refusing to pay for AcrySof IQ
I'm 52 years old and lived with severe monocular polyopia for years in my right eye from a cataract until vision in my left deteriorated enough (also due to cataract) so that I could have both eyes corrected properly at the same time. I was told that I really shouldn't be driving at night, my right eye was so bad (20/400 uncorrectable.) My doctor said that he would implant the AcrySof IQ (not the Toric, not the ReStor, but the SN60WF) He had been implanting that device as his primary choice in all patients for about 3 years. He did add that because I live over 50 miles from work and must drive that in the dark for nearly half the year, that the implant should provide some advantages (which are well documented.) I had both surgeries, the doctor and anesthesiologist were paid immediately, but the eye surgicenter wasn't. After a long delay, BCBSIL has now informed me that info from the surgicenter indicates that an ineligible device was implanted, so they will now retract all payments to the doctor and anesthesiologist, and will pay nothing to the surgicenter, leaving me on the hook for over $12,000. I find it quite odd that BCBSIL now refuses to pay anything at all for the surgery, when both the doctor and surgicenter have been reimbursed for this same implant and procedure for years (and I find it especially infuriating that Medicare will pay extra for an NTIOL and BCBSIL considers it "not medically necessary" and an "ineligible device".) Has anyone else had issues with a private payer refusing to pay in a similar circumstance? Neither the doctor nor the surgicenter gave me another option when it came to which implant was to be used; both pre-certified the procedure with BCBSIL, too.
Finally, I have the answer I have been wanting to hear from Alcon!
The person at Alcon in charge of reimbursement issues spoke to HCSC's director of medical policy.
He conceded that the SN60WF was improperly classified along with multifocal IOL's starting with that August 2008 revision to their medical policy and that there should be no issues with the claim.
My employer's insurance consultant is working with the general agency and BCBSIL to see how we can avoid having to file an appeal, because it seems that the people she can speak to at BCBSIL have told her the policy changed only as of October 14, 2009, and as my surgeries were in June and July, it's not clear as to how this should be handled.
At least the major hurdle has been cleared, now it will just take some additional paperwork and things should be fine!
The person at Alcon in charge of reimbursement issues spoke to HCSC's director of medical policy.
He conceded that the SN60WF was improperly classified along with multifocal IOL's starting with that August 2008 revision to their medical policy and that there should be no issues with the claim.
My employer's insurance consultant is working with the general agency and BCBSIL to see how we can avoid having to file an appeal, because it seems that the people she can speak to at BCBSIL have told her the policy changed only as of October 14, 2009, and as my surgeries were in June and July, it's not clear as to how this should be handled.
At least the major hurdle has been cleared, now it will just take some additional paperwork and things should be fine!
I'm sure that you'll ultimately win this battle, but Blue Cross appeals can involve a lengthy process. It might be possible to circumvent this by simply asking the parties involved to resubmit the paperwork to Blue Cross. The claims will probably land on someone else's desk, and they're likely to be processed without a problem. (If a payment has already been made by Blue Cross, the second claim will simply be rejected as a duplicate.) I've been successful with this tactic on more than one occasion.
It's not resolved, I still have a lot to do on this one, as the surgicenter told me that I have to do virtually all the legwork on the appeal.
Well, congratulations on getting the situation resolved. There was no doubt in my mind that it would be. I trust that the embarrassing mis-information will soon be deleted from Blue's website.
The consultant our small firm uses for benefits sourcing called BCBSIL and got nowhere (other than three people who read back the same line of policy to her.) During the call, she was obviously upset that she couldn't provide any more assistance.
Not one to give in, I called 800 numbers for Alcon until I found one with a live person who couldn't help, but made sure that I got through to someone who would.
This extremely helpful woman told me that she handled reimbursement issues with all insurers for Alcon IOLs, and when I told her the story, she almost didn't believe it. She sure knew what she was doing, as she immediately opened up the search page on the HCSC (BCBSIL parent) web site and accessed the page on IOL medical policy.
She was dumbfounded; she said that I was the first person to call Alcon to let them know that a claim involving implantation of the SN60WF had been rejected by a Blue based on a "medically not necessary" basis. The fact that HCSC had made that change, specifically placing the SN60WF on that list about a year ago was complete news to her.
And as you and I have noted, she said that the HCSC affiliates had to have been paying for these again and again for the last year because Alcon would definitely have heard about this sooner (especially considering that TX and IL are rather large states with many members.) And as we have surmised, she said that HCSC is improperly categorizing this implant along with others that are multifocal/accommodating, etc.
She gave me her name and number so that she can assist my doctor and the surgicenter with the filing of appeals, and told me that she was personally going to call the HCSC medical policy director and get answers. She thanked me several times for bringing this matter to Alcon's attention.
Just read that HCSC is trying to lay off 650 employees for cost cutting efforts. Gee, ya think that type of company news makes it easier to find anyone at an HCSC-owned Blue that will try to help a member get a dime more out of them than they want to pay?
Most people regret picking fights with me. HCSC/BCBSIL will too if I can do anything about it!
Not one to give in, I called 800 numbers for Alcon until I found one with a live person who couldn't help, but made sure that I got through to someone who would.
This extremely helpful woman told me that she handled reimbursement issues with all insurers for Alcon IOLs, and when I told her the story, she almost didn't believe it. She sure knew what she was doing, as she immediately opened up the search page on the HCSC (BCBSIL parent) web site and accessed the page on IOL medical policy.
She was dumbfounded; she said that I was the first person to call Alcon to let them know that a claim involving implantation of the SN60WF had been rejected by a Blue based on a "medically not necessary" basis. The fact that HCSC had made that change, specifically placing the SN60WF on that list about a year ago was complete news to her.
And as you and I have noted, she said that the HCSC affiliates had to have been paying for these again and again for the last year because Alcon would definitely have heard about this sooner (especially considering that TX and IL are rather large states with many members.) And as we have surmised, she said that HCSC is improperly categorizing this implant along with others that are multifocal/accommodating, etc.
She gave me her name and number so that she can assist my doctor and the surgicenter with the filing of appeals, and told me that she was personally going to call the HCSC medical policy director and get answers. She thanked me several times for bringing this matter to Alcon's attention.
Just read that HCSC is trying to lay off 650 employees for cost cutting efforts. Gee, ya think that type of company news makes it easier to find anyone at an HCSC-owned Blue that will try to help a member get a dime more out of them than they want to pay?
Most people regret picking fights with me. HCSC/BCBSIL will too if I can do anything about it!
Then if Blue Cross follows the policy as written, they won't pay for the majority of cataract surgeries. This makes no sense, because Medicare and all other insurance providers will pay. If you make sure that the surgery center, your anesthesiologist, and your surgeon's office are aware of the billing problem, I think that you've done all you can do. Have faith that this will soon be worked out (maybe with just a single phone call from the surgery center to Blue Cross--but not to the idiot who is handling your claim).
BCBSIL already paid my doctor, whose practice is separate from the eye surgicenter, for both surgeries. Three parties billed BCBSIL separately: my doctor, the anesthesiology practice, and the surgicenter (owned by another group of ophthalmologists; my doctor has no financial interest in that facility.) Under standard filing procedure, apparently to conform with Medicare requirements, the surgicenter is the party who must include the fee for the implant in the cost of their services. My doctor never, ever bills BCBS for implants as he does not supply them.
The only party that was not paid quickly was the surgicenter, who is the party that supplied the implants. It was only after BCBSIL asked for and received the operative reports from the surgicenter (they did not get them from my doctor!) in which the SN60WF was identified that they said they wouldn't pay, and that they would retract all payments already made to my doctor and the anesthesiologist.
When I brought a copy of the policy into his office and he read it, you should have seen the look on his face. He was dismayed because he agrees that the policy now clearly states that the SN60WF is considered medically unnecessary, and that he can't change his operative report. Thus, if BCBSIL follows the policy as written, they won't pay.
The only party that was not paid quickly was the surgicenter, who is the party that supplied the implants. It was only after BCBSIL asked for and received the operative reports from the surgicenter (they did not get them from my doctor!) in which the SN60WF was identified that they said they wouldn't pay, and that they would retract all payments already made to my doctor and the anesthesiologist.
When I brought a copy of the policy into his office and he read it, you should have seen the look on his face. He was dismayed because he agrees that the policy now clearly states that the SN60WF is considered medically unnecessary, and that he can't change his operative report. Thus, if BCBSIL follows the policy as written, they won't pay.
Actually, I believe that ReZoom is a refractive IOL and not aspheric. (AMO's Tecnis multifocal lens is aspheric, and so are the more recent ReStor models.) And who was the idiot who told you that "nothing could be changed or reconsidered?" Ha! Just wait and see!
I assume that the person in your sugeon's office who is responsible for submitting insurance claims has substantial experience doing so. Let him/her handle this. The bottom line is that the surgeon is not going to get paid until this is resolved. If it becomes necessary to educate BCBS personnel about cataract surgery today and the IOLs currently used, then let the surgeon do it. He has more authority than a lowly patient or an office administrator.
I assume that the person in your sugeon's office who is responsible for submitting insurance claims has substantial experience doing so. Let him/her handle this. The bottom line is that the surgeon is not going to get paid until this is resolved. If it becomes necessary to educate BCBS personnel about cataract surgery today and the IOLs currently used, then let the surgeon do it. He has more authority than a lowly patient or an office administrator.
Precisely what I thought.
I erred a bit, what I originally quoted was from the October 2008 update, not the August 2008. Here's the language from the August update, which actually seems to be more definitive:
"Non-refractive aspherical intraocular lenses (i.e. ReZoom™, SofPort®, AcrySof® SN60WF, Tecnis™ Z9000) are considered not medically necessary and primarily for the convenience of the member."
ReZoom is aspheric/refractive, as far as I can tell. The original Tecnis Z9000 is aspheric/monofocal as is the SN60WF. SofPort is also aspheric/monofocal. So yes, it does appear that the statement contains some inconsistencies, but the initial part of that statement does seem to be clear. As to why the term "non-refractive" was eliminated from the last update.....gee, could it be that someone decided that making it more vague could result in some cost savings?
That medical policy is for BCBS in IL, TX, NM, and OK, so I'd have to presume as you do that they have actually paid for a huge number of aspheric monofocal IOL's without knowing or asking enough to know.
However, I was told that because my doctor's operative reports clearly indicate that the SN60WF was implanted in both cases, there was nothing that could be changed or reconsidered. He obviously can't go back and change them.
I erred a bit, what I originally quoted was from the October 2008 update, not the August 2008. Here's the language from the August update, which actually seems to be more definitive:
"Non-refractive aspherical intraocular lenses (i.e. ReZoom™, SofPort®, AcrySof® SN60WF, Tecnis™ Z9000) are considered not medically necessary and primarily for the convenience of the member."
ReZoom is aspheric/refractive, as far as I can tell. The original Tecnis Z9000 is aspheric/monofocal as is the SN60WF. SofPort is also aspheric/monofocal. So yes, it does appear that the statement contains some inconsistencies, but the initial part of that statement does seem to be clear. As to why the term "non-refractive" was eliminated from the last update.....gee, could it be that someone decided that making it more vague could result in some cost savings?
That medical policy is for BCBS in IL, TX, NM, and OK, so I'd have to presume as you do that they have actually paid for a huge number of aspheric monofocal IOL's without knowing or asking enough to know.
However, I was told that because my doctor's operative reports clearly indicate that the SN60WF was implanted in both cases, there was nothing that could be changed or reconsidered. He obviously can't go back and change them.
My cataract surgery was prior to August 2008, but I find this change unbelievable. Aspheric monofocal IOLs are probably the most commonly used implant. The quoted information (above) is crazy--Rezoom is NOT an aspheric IOL.
BCBS is a major insurer, and they have undoubtedly already paid for hundreds of cataract procedures using aspheric monofocal IOLs peformed by your surgeon at your surgery center during the past year. In your place, I'd inform the parties responsible for submitting your paperwork to Blue Cross about the problem, and then I'd let them work this out with Blue Cross. Possibly, your claim fell on the desk of someone who is either really new at this type of work or obviously not very good at it. Possibly, just re-submitting the claim (omitting the name of the implant used) would work. (After all, hundreds of other claims involving aspheric monofocal implants have been paid since August 2008.)
BCBS is a major insurer, and they have undoubtedly already paid for hundreds of cataract procedures using aspheric monofocal IOLs peformed by your surgeon at your surgery center during the past year. In your place, I'd inform the parties responsible for submitting your paperwork to Blue Cross about the problem, and then I'd let them work this out with Blue Cross. Possibly, your claim fell on the desk of someone who is either really new at this type of work or obviously not very good at it. Possibly, just re-submitting the claim (omitting the name of the implant used) would work. (After all, hundreds of other claims involving aspheric monofocal implants have been paid since August 2008.)
Thanks, Jodie, and yes, the outcome has been excellent. Having been an extreme myope since age 8, driving without glasses with just a trace of astigmatism is wonderful!
Just curious, though, when was your surgery complete?
Believe it or not, BCBSIL directed me to a web link in their Medical Policy on IOL's that was changed in August 2008, and now states:
"Aspherical intraocular lenses (i.e. ReZoom™, SofPort®, AcrySof® SN60WF, Tecnis™ Z9000) are considered not medically necessary and primarily for the convenience of the member."
The updates previous to August, 2008 do not include this language, and the BCBSIL rep told me that it was the specific reference to the SN60WF in the report from the surgicenter that set this in motion. Apparently a code that indicates an NTIOL was implanted always starts a more detailed investigation to find out if it's one that they believe to be unnecessary!
An MD friend believes that someone at BCBSIL has incorrectly presumed that all aspheric lenses either provide refractive correction or are accommodative. He has a large and very well respected practice in the Indianapolis area, and likewise has never had an issue with an Indiana BCBS reimbursement when using the SN60WF, which is also his implant of choice. I've accessed as many other state BCBS medical policies as I could via a Google search, and none of them indicated the SN60WF was medically not necessary or an ineligible device.
Just curious, though, when was your surgery complete?
Believe it or not, BCBSIL directed me to a web link in their Medical Policy on IOL's that was changed in August 2008, and now states:
"Aspherical intraocular lenses (i.e. ReZoom™, SofPort®, AcrySof® SN60WF, Tecnis™ Z9000) are considered not medically necessary and primarily for the convenience of the member."
The updates previous to August, 2008 do not include this language, and the BCBSIL rep told me that it was the specific reference to the SN60WF in the report from the surgicenter that set this in motion. Apparently a code that indicates an NTIOL was implanted always starts a more detailed investigation to find out if it's one that they believe to be unnecessary!
An MD friend believes that someone at BCBSIL has incorrectly presumed that all aspheric lenses either provide refractive correction or are accommodative. He has a large and very well respected practice in the Indianapolis area, and likewise has never had an issue with an Indiana BCBS reimbursement when using the SN60WF, which is also his implant of choice. I've accessed as many other state BCBS medical policies as I could via a Google search, and none of them indicated the SN60WF was medically not necessary or an ineligible device.
BCBS (PPO) of Illinois paid for the entire cost of both my cataract surgeries with AcrySof IQ lenses, and I'm sure that their policy regarding these implants has not changed.
I suspect that there is an error in the paperwork submitted for you, and unfortunately you (or, better yet, the people who filled out the paperwork) will have to track down the problem and correct it. I recently had a perfectly legitimate claim to Blue Cross rejected outright, and upon investigation I discovered that it had been submitted by my doctor's billing agent without a provider number. Correcting this error solved the problem. Since your surgeon and the surgicenter undoubtedly want to get paid ASAP, they should be highly motivated to help you with this.
BTW, my outcome with the AcrySof IQs was really excellent, and I've never experienced even a minor problem with these IOLs. I hope you're enjoying the same good results as me.
I suspect that there is an error in the paperwork submitted for you, and unfortunately you (or, better yet, the people who filled out the paperwork) will have to track down the problem and correct it. I recently had a perfectly legitimate claim to Blue Cross rejected outright, and upon investigation I discovered that it had been submitted by my doctor's billing agent without a provider number. Correcting this error solved the problem. Since your surgeon and the surgicenter undoubtedly want to get paid ASAP, they should be highly motivated to help you with this.
BTW, my outcome with the AcrySof IQs was really excellent, and I've never experienced even a minor problem with these IOLs. I hope you're enjoying the same good results as me.
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