On behalf of a client, we have a great success story to report. One of our oncology clients was having continued denials with a large private pay insurance company. Regarding this particular situation, the oncologist was following AMA coding guidelines, however, the insurance company did not agree. The issue at hand was relative to CPT 96413, used for initial drug infusion, along with CPT 96416, used for chemotherapy administration via IV infusion (when patients are sent home with a pump).
The physicians were doing chemo and charging the administration and chemo fee. The insurance company told them only one charge could be “initial”, and that they would not be able to bill these codes together on the same day for the same patient. This started in October of 2006. They received continued denials. We exhausted the official appeals process for this physician. We then participated in a conference call with the insurance company and their legal department. The results of that call were still negative. We provided them with more information and documentation.
Fast forward a year later. They reversed their decision. We won. The oncologist won. Reimbursements will be made retro to January of 2006. This was a huge win for a solo practitioner. Persistence pays off.
If you have success stories please let us know what they are. We will share them.