October 1999: Postoperative Care

TO: ARS Members
FROM: ARS Socioeconomic Committee (Joseph B. Jacobs, M.D., Chairman; Fred Kuhn, M.D.; Paul Toffel, M.D.; Robert Bumstead, M.D.; James Pitcock, M.D.)
RE: Proposed Strategy on Challenging Inappropriate Payer Policies
DATE: October 1999


With the assistance of outside legal counsel, the SocioEconomic Committee has proposed the following strategy for ARS members to employ in challenging inappropriate payer policies with respect to FESS:
The SocioEconomic Committee will act as a repository and disseminator of information with respect to payer policies both good and bad. To that end, the Committee has attached to this packet a survey for each member to complete. The Committee will periodically survey for each member to complete. The Committee will periodically circulate this information in the ARS Newsletter. It is hoped that members will be able to use the information that certain payers have good policies to persuade other payers to adopt similar policies. Members may also use the information that certain payers have inappropriate payment policies. To decide not to participate with those payers.

To the extent that you do not know formally what payment policies payers in your area have with respect to FESS, we encourage you to find out. Particularly, you might with to focus on payer policies with respect to post-operative billing of 31231 and 31237. You may collect this information with the assistance of other rhinologists in your area.

The Committee encourages members to challenge inappropriate payer policies. Attached is a letter from ARS outside legal counsel that could be sent by you to your payer if the issue is post-operative billing of 31231 and 31237. We encourage you to follow up the letter with a meeting with the medical director of the payer. We advise against meeting with lower level payer representatives. You may wish to have other rhinologists in your community accompany you to the meeting. You should demand that the payer provide its authority to establish a 90 day global period for FESS procedures and the experience and training of any payer medical consultant with FESS.

If the medical director refuses to change the payer's policy, consider pursuing other alternatives that include, requesting an administrative fair hearing on the payment denial; contacting your State Insurance Commissioner, Attorney General's Office, Chamber of Commerce, Better Business Bureau, and local press. You could pursue a court challenge. However, such an endeavor is expensive and success can never be assured.

As stated above, we encourage you to work with other rhinologists in your area to resolve inappropriate payer policies. You may work cooperatively with respect to informing the payer about FESS procedures and persuading the payer to change its policy. Ultimately, a rhinologist may decide not to participate in a plan if the payment policy is inappropriate. The rhinologist always has the right to opt out and to inform patients of a payer's unreasonable policies. Rhinologists may not, however, join together in a group boycott of a payer. It may be, however, that when a particular payer's policy is well known in the community, a number of rhinologists independently and separately come to the same conclusion that nonparticipation with that payer is the only reasonable conclusion. If a number of rhinologists independently come to that same conclusion that action is legal.

Please keep us informed of your activities. All correspondence should be sent to:

Joseph B. Jacobs, M.D.
Chairman, SocioEconomic Committee
American Rhinologic Society
Department of Otolaryngology
New York University Medical Center
530 First Avenue - Suite 3C
New York, NY 10016-6402

 

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Revised 10/1999