Cigna Denials per their Reimbursement Policy

mglynn431

Is anyone seeing denials from Cigna where they determine that certain billed charges do not meet the criteria for payment according to the hospitals agreement with Cigna.They refer to Cigna Reimbursement Policy which can be found on their website: R14; R12; R09 and R16?  Example:  They do not want to pay for drugs used in the operating room and they reference Cigna Policy R12. If you go to the website you will find that policy R12 states that routine service or supplies not separately billable - inclusive in operating room charge per Cigna policy R12. Need suggestions on how to fight these denials.  I am currently filing a level 1 appeal with Cigna and supplying them with a line item spreadsheet along with documentation from the medical record to support each denied supply/services.  The typical response from  Cigna is "After reviewing your request, we have decided to uphold the original decision" Any and all suggestions on how to handle these denials would be greatly appreciated.

dwilliamsrsi

You mention that they don't want to "pay for drugs used in the operating room."  I take it that the contract provides for a percent of charge type of reimbursement.  If so, is there a difference in the percent they pay based on revenue code?  If they reimburse 0250 or 0636 at a lower percentage than 0360, for example, you can argue that this is less expensive for them than if you charged a "lump sum" for everything used during surgery. It can be successful when it comes out to their advantage.  You may also need to get your Managed Care/Contracting staff involved in the appeal.   An alternative going forward - You can support the charge based on the CMS requirements that you must charge all patients/payers the same.  However, what that looks like on the claim can be very different.  You can charge for the drugs separately, but if a payer wants to balk that it should not have been on the claim as a separate charge, then you can roll the drug charge into the OR charge.  It can seem a little discrepant, but the claim can reflect the services reported as the payer needs/wants them to be - you can still prove from the itemized statement that you charged all patients the same.  You would just have an overall policy that states "we charge all patients the same based on our charge structure; we will represent the claim as defined by each payer" or something to that effect.  I would also check the contract to be sure that this was agreed upon.  Next contract round, there is an opportunity to refine the language to represent your charging vs. billing policy.  

mglynn431

Thank you so much for taking the time to respond to my post.  Great information. I will share this information with my boss, change the verbiage in my response to Cigna and get the contract people involved.