BCBSIL Billing for Medically Unnecessary and/or Medically Unproven Services

BCBSIL Billing for Medically Unnecessary and/or Medically Unproven Services

In its most recent issue of the Blue Review, Blue Cross Blue Shield of Illinois (BCBSIL) announced billing conditions it will impose on providers who treat BCBSIL patients.

BCBSIL has stated:

“Effective for dates of service on or after July 14, 2014,* claims submitted to BCBSIL for services that are deemed to be medically unnecessary and/or medically unproven (experimental and investigational) will be denied with a message specifying that the member will not be financially responsible for charges associated with…any outpatient procedure or other services that are determined by utilization management to be medically unnecessary and/or medically unproven.

Medically Unproven Services

If you and your patient are aware that a proposed service will be deemed medically unnecessary and/or medically unproven and you decide to proceed, you must obtain a written disclosure/authorization…informing the [patient] that services are not covered by BCBSIL and the patient is assuming all financial responsibility.  The dated disclosure/authorization must state that the member has been informed prior to services being rendered that the services are not covered; it also must include the total cost of services and confirmation that the member accepts all financial responsibility.”

The ICS does not concede that any health plan has the right to supersede a financial agreement between a health care provider and patient, especially when the provider is not a member of the health plan network.  In addition, despite the provider’s best due diligence prior to providing service, it is not always possible to determine with 100% certainty whether a health plan will cover the particular service.  This can occur for a number of reasons, including but not limited to:  the health plan may disclaim that pre-verification is a guarantee of payment; the provider may determine during the treatment itself that it is in the patient’s best medical interests to revise treatment; services that are initially covered may become non-covered when they reach a point determined by the health plan to be maintenance care; or because a post-payment audit results in a refund demand by the health plan long after treatment and payment have been concluded. 

Recommendations

In order to provide the required notice of financial responsibility for services not covered by insurance, the ICS recommends that its doctors obtain the patient’s or responsible party’s signature on the attached form prior to each date of service.  Although it may seem cumbersome to add the signing of an additional form to each visit, this procedure documents that the doctor has identified the procedure(s), along with the date and cost.

The ICS understands that this policy requires our doctors to perform what may be an impossible task in some cases:  Because the CPT® coding manual defines “chiropractic manipulative treatment (CMT)” to include a pre-manipulation patient assessment, this service often serves as both a diagnostic and a therapeutic procedure.  In some cases, the doctor will need to perform the CMT to diagnose the patient and to determine the required procedures, the regions where they are required and the anticipated cost.  Therefore, in some cases, it could be very difficult, if not impossible, to provide an exact estimate to a patient prior to rendering the service.   Nonetheless, the ICS recommends that doctors use the information available to provide the patient with the best estimate of the upper range of anticipated cost.   In addition, there may be some services that the provider initially believes are covered, but ultimately are determined to be non-covered.  The ICS believes this form will cover all of these services to the extent feasible. 

Conclusion

Providing information to the patient in this manner according to the form will afford the best opportunity to maintain the patient’s financial responsibility for services not covered by insurance, should it be challenged at a later date. The ICS will continue to monitor this issue and will keep members apprised as to additional developments.

Template Notification Form

*BCBSIL initially announced an implementation date of May 19, 2014, but has revised it to July 14, 2014.

“CPT Copyright 2017 American Medical Association. All rights reserved.
CPT® is a registered trademark of the American Medical Association.”

About Author

Marc Abla, CAE

Marc Abla began working at the Illinois Chiropractic Society in 2002 and became the Executive Director in 2008. He brings his extensive financial, administrative and association experience to the ICS. He is a Certified Association Executive and a graduate of the Certified Leadership Series through the Illinois Society of Association Executives. Additionally, he is a member of the Illinois Society of Association Executives, the American Society of Association Executives, Association Forum, Congress of Chiropractic State Associations, and the American Chiropractic Association.


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