Transitioning commercial RFA to Medicare

[bedrock]

There are several insurance companies that cover 3 joint bilateral RFA in my state (Cigna, UHC, and Aetna)

Medicare no longer does, as we all know.

I have recently seen several patients just before Medicare age (63yrs old, for example) with facets bad enough that they would benefit from 3 joint bilateral RFA and so I’ve done that for them with great results.

The question is how to handle the insurance side of things 2 years later when they transition to Medicare as Medicare only covers two joint bilateral RFA?

I generally give these patients the option to pay for the extra level in cash while I do the other levels under Medicare. (And no I’m not going to do two extra joints for free, every year for 20 years, once they turn 65 because the government decided to spend that extra money on wasteful government programs instead of medical care for their citizens)

My question to the group concerns MBB and Medicare RFA authorization. If I do bilateral L2-L5 MBB and RFA under commercial insurance, and I’m reducing a level (one fewer bilateral joints) for patients who just turned 65 and that patient wants RFA just for the two bilateral joint covered by Medicare, are there any medicare chargeback issues to simply changing their first RFA after age to L3-L5, or to be on the safe side do I need to repeat L3-L5 MBB once they turn 65 and are on medicare?

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[callmeanesthesia]

There are several insurance companies that cover 3 joint bilateral RFA in my state (Cigna, UHC, and Aetna)

Medicare no longer does, as we all know.

I have recently seen several patients just before Medicare age (63yrs old, for example) with facets bad enough that they would benefit from 3 joint bilateral RFA and so I’ve done that for them with great results.

The question is how to handle the insurance side of things 2 years later when they transition to Medicare as Medicare only covers two joint bilateral RFA?

I generally give these patients the option to pay for the extra level in cash while I do the other levels under Medicare. (And no I’m not going to do two extra joints for free, every year for 20 years, once they turn 65 because the government decided to spend that extra money on wasteful government programs instead of medical care for their citizens)

My question to the group concerns MBB and Medicare RFA authorization. If I do bilateral L2-L5 MBB and RFA under commercial insurance, and I’m reducing a level (two joints) for patients who just turned 65 and that patient wants RFA just for the two bilateral joint covered by Medicare, are there any medicare chargeback issues to simply changing their first RFA after age to L3-L5, or to be on the safe side do I need to repeat L3-L5 MBB once they turn 65 and are on medicare?

The Medicare LCD at least in my area allows a third level with documentation of the circumstance that requires it. I generally put something like “The third level is medically necessary because the patient has extensive degenerative changes and tenderness to palpation over greater than 2 facet joint levels. They have had >50% relief for over 6 months from prior 3 level RFA procedures. Narrowing the procedure down to 2 levels would require additional rounds of medial branch blocks, which would serve no legitimate medical purpose, only a bureaucratic one to satisfy an arbitrary insurance limit.”

If the patient had a 2 level MBB done with inadequate relief before going on to the 3 level procedure I add that in there as additional proof that 3 levels is necessary. I’m not doing the third level commonly - mostly for the people with degenerative scoliosis and terrible facets throughout.

I’m getting at least some, possibly most of the third levels covered. Probably time to have my billers re-run a query on it…

 

[bedrock]

The Medicare LCD at least in my area allows a third level with documentation of the circumstance that requires it. I generally put something like “The third level is medically necessary because the patient has extensive degenerative changes and tenderness to palpation over greater than 2 facet joint levels. They have had >50% relief for over 6 months from prior 3 level RFA procedures. Narrowing the procedure down to 2 levels would require additional rounds of medial branch blocks, which would serve no legitimate medical purpose, only a bureaucratic one to satisfy an arbitrary insurance limit.”

If the patient had a 2 level MBB done with inadequate relief before going on to the 3 level procedure I add that in there as additional proof that 3 levels is necessary. I’m not doing the third level commonly - mostly for the people with degenerative scoliosis and terrible facets throughout.

I’m getting at least some, possibly most of the third levels covered. Probably time to have my billers re-run a query on it…

How often are you getting 3 bilateral joint RFA covered?

I do recall that Medicare will cover unilateral 3 joint RFA if you add documentation of necessity such as severe scoliosis, torticollis etc

However, I haven’t seen that Medicare will consistently cover bilateral 3 joint RFA, even with documentation of need.

 

[Ferrismonk]

Well, Medicare is requiring pre-authorization for facet stuff in a couple days anyway. I would just go down to the two levels when the patient changes insurance and tell them that's how government works. You should (ideally anyway) be able to just document the prior RF relief and avoid the need to do new MBBs.

 

[bedrock]

Well, Medicare is requiring pre-authorization for facet stuff in a couple days anyway. I would just go down to the two levels when the patient changes insurance and tell them that's how government works. You should (ideally anyway) be able to just document the prior RF relief and avoid the need to do new MBBs.

What is the new policy to pre auth facet procedures? I thought they were doing something for hospitals (but not ASC/office procedures), correct?

 

[Ferrismonk]

Ah, that's fair. HOPD only for now.

 

[Ducttape]

in the extremely rare occasion that i decide to carpet bomb the lumbar spine, i ask for auth for bilateral L34 and L5S1 facets.

2 levels. i dont remember having an issue with any insurer denying coverage.



getting it approved in the first place and doing the procedure is much more important to me than the small amount of wRVU i lose not biling that 3rd level. yes, clearly, that is not everyones opinion...

 

[myrandom2003]

So now that medicare requires prior auth for HOPD procedures, is it easier to get that third level approved with documentation?

 

[Laryngospasm]

I carpet bomb fairly often. Sometimes I fuel/air bomb too!

 

[Agast]

in the extremely rare occasion that i decide to carpet bomb the lumbar spine, i ask for auth for bilateral L34 and L5S1 facets.

2 levels. i dont remember having an issue with any insurer denying coverage.



getting it approved in the first place and doing the procedure is much more important to me than the small amount of wRVU i lose not biling that 3rd level. yes, clearly, that is not everyones opinion...

This is how I do my MBB/RFA and every time I do the procedure I think about how I’m kowtowing to the man and they’ve figured out how much more they can squeeze out of me. Because I will slit my wrists if one more patient tells me “Ackshully I called my insurance and they said they *would* cover it but you’re just submitting it wrong”

 

[DrMDAware]

a colleague splits up his bilateral rfas into two separate sessions targeting each side during a visit.

I get it - not his fault the insurance company pays 50% for the other side. The risk is the same so why half the payment?

And to your point the patients will cry “well it IS covered” but they fail to realize being covered is not the same as the amount paid.

 

[BobBarker]

I used to split when working for the hospital but in private practice bilateral is the way to go. Save $50 on disposables and can repeat in 6m if needed. Usually, I start to have issues 9-10M after the RFA with pain coming back.

 

[MitchLevi]

I used to split when working for the hospital but in private practice bilateral is the way to go. Save $50 on disposables and can repeat in 6m if needed. Usually, I start to have issues 9-10M after the RFA with pain coming back.

Agree, and it keeps the line moving quicker so referrals are seen in a timely manner.

 

[Dr. Ice]

I have never split the bilaterals up. Also honestly it’s not the patients fault that their insurance is a piece of garbage. Why should they have to come back twice for a procedure

 

[Ducttape]

a colleague splits up his bilateral rfas into two separate sessions targeting each side during a visit.

I get it - not his fault the insurance company pays 50% for the other side. The risk is the same so why half the payment?

And to your point the patients will cry “well it IS covered” but they fail to realize being covered is not the same as the amount paid.

this may get clawed back. you can bill for it separately, but the reimbursement for that second session is supposed to remain at 50%.

this occurred to me with one of the medicaid plans. in addition, that particular plan counted that 2nd session as a completely separate session out of the 5 that the patient is allowed per year.

 

[DrMDAware]

I have never split the bilaterals up. Also honestly it’s not the patients fault that their insurance is a piece of garbage. Why should they have to come back twice for a procedure

It’s not the patients fault you are correct. Why should I be paid less, though?

this may get clawed back. you can bill for it separately, but the reimbursement for that second session is supposed to remain at 50%.

this occurred to me with one of the medicaid plans. in addition, that particular plan counted that 2nd session as a completely separate session out of the 5 that the patient is allowed per year.

I’ll see if it gets clawed back. I’ll keep you posted!

I don’t take Medicaid.

 

[DrMDAware]

I used to split when working for the hospital but in private practice bilateral is the way to go. Save $50 on disposables and can repeat in 6m if needed. Usually, I start to have issues 9-10M after the RFA with pain coming back.

I’m straight $ per wRVU. Does that change the picture?

 

[BobBarker]

You get more wrvu for splitting the sides over two occasions.

 

[cowboydoc]

I’m straight $ per wRVU. Does that change the picture?

Depends on turnover time and how busy you are. You still make 50% on the other side, but no prep, turnover time.

I’m always doing bilateral (except some cervicals will split). I have a seemingly endless supply of patients, usually a backlog, and turnover time is longer than it takes to do contralateral burn. I don’t want patients to have additional hassle and cost.

I’m anesthesizing the right side while the left is burning, only takes a few more minutes.

 

[buddababa]

Depends on turnover time and how busy you are. You still make 50% on the other side, but no prep, turnover time.

I’m always doing bilateral (except some cervicals will split). I have a seemingly endless supply of patients, usually a backlog, and turnover time is longer than it takes to do contralateral burn. I don’t want patients to have additional hassle and cost.

I’m anesthesizing the right side while the left is burning, only takes a few more minutes.

same

 

[DOctorJay]

Depends on turnover time and how busy you are. You still make 50% on the other side, but no prep, turnover time.

I’m always doing bilateral (except some cervicals will split). I have a seemingly endless supply of patients, usually a backlog, and turnover time is longer than it takes to do contralateral burn. I don’t want patients to have additional hassle and cost.

I’m anesthesizing the right side while the left is burning, only takes a few more minutes.

the insurance companies are banking on our altruism

 

[cowboydoc]

the insurance companies are banking on our altruism

So is admin.