Surgeon's assistant appeal letter?

Question

Does anyone have an effective appeal letter for a surgeon's assistant denial they would like to share? It would be greatly appreciated.

Answer 1

You didn't state the reason the insurance company refuses to pay it, but, based on what I've seen, am I correct that the insurer says the assistant's fee is included in the surgeon's fee? Such denials are permitted, IF the scenario fits the insurer's coding guidelines. Unusual cases requiring extensive work by both surgeons are usually reimbursed separately.

I'm assuming you work in a doctor's office as a coder, biller, or are in charge of appeals? If so, before you write your appeal letter, pull out your office contract and read it carefully; then, pull out your Provider Manual and look for coding guidelines related to this (my memory tells me this is a modifier 80). If you don't get answers from either of these sources, call the insurer and ask to have a copy of its coding guideline for this procedure and the modifier(s) you used.

It's usually a good idea to attach a copy of the operative report to the appeal, especially if you are arguing that the assistant performed separately reimbursable services.

If you're a consumer trying to fight this, I recommend calling your state's insurance commissioner's office. These types of denials are difficult to appeal by a consumer.

I hope this helps. If you want to send me a message with additional details, I'd be happy to give further advice or clarification based on the reason for the denial.

Answer 2

Denial of what??? In denial that he's a surgeon's assistant?? What was the denial reason? There is no generic appeal letter, except "I appeal!!" In order to get some help with this, you need a LOT more details.

Assuming there's an insurance policy involved, you should get your agent to help you write it. It's one of those "value added" services they should be providing.

Answer 3

I like Suzanne's response (since the reason for the denial could range from not enough information to pre-authorization issues to the original underlying claim is denied), but would like to add the following. It wold also depend on the type of insurance being claimed and what jurisdiction is involved. These play a role the process of the appeal.

Answer 4

It can't hurt. Sometimes you just need to ask. On the other hand, I get awfully sick of (usually young) people blabbing or texting on their phones while they weave all over the place in traffic. People on phones are worse than drunkards on the road. The classic is going 20 mph above or below the speed limit weaving all over the place, just like someone who's about to blow a .25. Good luck. To be honest, if you've had this type of infraction before, I wouldn't hold my breath.

Answer 5

Do anyone have a appeal letter for being denied due to out of network?

Answer 6

Denial of what? Service for a patient?