FAPA Member Wins Reversal of Claims
--by C. Hamilton Boone, PA-C of Physician Assistant Services, Inc.
pas@paservices.net

Greetings. I wanted to share with you an experience that I recently had. The experience of having an insurance company being “put into line” was extremely satisfying. Even though my experience occurred in the surgical arena, I feel that the fundamentals I used can be applied in the medical arena as well. My hope is that the word will get out about this success, so other PAs and their practices can experience the same.
 
My surgical PA practice, Physician Assisting Services had been experiencing persistent reimbursement problems with Tricare/Humana. Tricare/Humana was denying services that were deemed necessary by the CMS (Centers for Medicare and Medicaid Services) and the ACS (American College of Surgeons). Specifically, these problems came in the form of denial of claims for assisting our surgeons on certain General, Orthopedic and Obstetric cases.
 
Physician Assistant Services utilizes 3 separate criteria before agreeing to assist:
1) The procedure must Pre-authorized.
2) The procedure meets CMS guidelines for an assistant at surgery.
3) The procedure meets ACS guidelines for an assistant at surgery.

 
Despite adherence to these insurance industry guidelines, Tricare decided to “invent” their own guidelines, arbitrarily choosing to deny payment for an assistant at surgery that met all 3 guidelines. We had never experienced this phenomenon. Excluding self-funded programs, all other carrier(s), private or federal reimburse for assistant at surgery if all 3 criteria are met. After months of trying to “reason” with the “unreasonable”, I finally had enough and decided to fight back. At that time PAS had approximately 11 claims that were denied, dating back to 2004.
 
I contacted my congressman, Dave Weldon, MD for help. It was suggested that I put a letter together outlining the problem and submit it to the Congressman. I submitted my letter of complaint along with the signatures of 9 surgeons that joined the complaint. It took some approximately 2 ½ months, but including the surgeons and my 11 claims; so far approximately 108 claims have been reversed. I cannot say enough about the hard work by congressman Weldon’s staff and the tenacity they displayed in solving this dilemma. You may contact his office at 321-632-1776 and ask for Pam Gillespie or Toni Mahoney.
 
The following logic was used for my argument:
1) That we adhered to the industry standard guidelines set by CMS and ACS for assistants at surgery.
2) The procedure was preauthorized through the surgeon’s office.
3) According to Chapter 4,Sec 4.1 of the Tricare manual, we were covered.

 
If you or anyone you know is having problems with Tricare/Humana reimbursing, please contact me and I will forward the information to you. I have all the documents I have used at your disposal via email.