At 08:24 PM 8/3/2004, Ajey Godbole wrote:
----- Original Message -----
From: Ajey Godbole
To:
Sent: Tuesday, August 03, 2004 10:23 PM
Subject: BCBS not paying for ADHD
I was informed by my billing manager that BCBS of Texas is not paying the
practice for a patient with ADD (without H) I have seen 6 times in the office
already. Apparently they and a lot of other insurance companies in Texas are
not paying for 'mental health' diagnoses if billed by a primary care provider.
They will only pay for these diagnoses if seen by a 'mental health
professional'. The subliminal msg. is: bill for 'something else' and it will
get paid.
I wonder if any of you has run into this. I am drafting a letter to send with
an appeal of the denials and I plan to fight it for months if necessary but my
manager tells me it is futile!
=ajey
If you're seeing the patient specifically for ADD management and that's the
reason they're coming into the office, then it should be billed using ADD
and if denied the family is responsible for the charges. Unfair, yes, but
those are the health insurance benefits (or lack thereof) that the family
either chose or had foisted upon them by an employer. Just like Blue Cross
of California won't pay for well child visits once a child reaches their
seventh birthday - it's spelled out very clearly in the fine print of the
insurance benefits book. Blue Cross also won't pay for the diagnoses
"overweight" or "excess weight gain", because "weight loss management" is
considered a non-covered benefit. If there's a legitimate other problem
discussed and managed at the visit, though, then there's nothing wrong with
billing using that diagnosis as long as the office note supports it.
I'll also respectfully disagree with Harry's statement, "They may be saying
"no" just to see if you're interested." I say that they're saying "no"
because, unless BCBS of Texas is a non-profit, they've simply found another
way of avoiding paying claims and increasing their profit and they'll
continue to do so kicking and screaming until they're forced to either by
bad publicity or pressure from the AAP. But they're probably hoping that
most providers don't have the time or energy to do their own "kicking and
screaming" and will either bill the family or (as many of us often do)
write off the visit.
Michael Sachs, M.D.