JAN 12, 2016
Payment Denials from Commercial Plans for Office-Based Surgical Procedures
Question: We were denied payment from commercial plans for office-based surgical procedures such as strabismus surgery and vitrectomy. We submitted a reconsideration, which was also denied. Medicare covers the office-based surgeries, why doesn’t the commercial plan?
Answer: Each payer has their own rules and regulations. Many commercial plans do not have a fee schedule for surgical cases typically performed in a facility setting. When calling for preauthorization/precertification, best to ask for an allowable (in this case, in the office setting), and the global period (as it could also vary from Medicare Part B).