Stop Denying It: Billing Claims In Reduction Mammaplasty
Carter J. Boyd, MD, MBA1, Joshua Cohen, MD1, Kshipra Hemal, MD1, David A. Daar, MD, MBA1, John Gwin, BA2, Karen Zupko, BA3, Nolan S. Karp, MD1.
1NYU Langone, New York, NY, USA, 2The Auctus Group, Delray Beach, FL, USA, 3Karen Zupko & Associates, Chicagio, IL, USA.
PURPOSE: Despite evidence documenting the physical and psychological benefit of breast reduction, insurance claims remain a cumbersome process. The objective of this study was to assess denials of insurance claims for reduction mammaplasty in a national cohort.
METHODS: We partnered with the Auctus Group to prospectively collect data on all of their plastic surgery clients with denied breast reduction claims (CPT 19318) from January 2022 through August 2022. Data harvested included claim status, reason for denial, network status and other related variables. Descriptive statistics were performed where appropriate.
RESULTS: There were 216 denials from insurance companies during this period with an average of 1.37 denials per claim. Of the 158 initial denials, 104 (65.8%) of these were from claims that had already received prior-authorization. Of the remaining 34.1% denied claims, third-party payers stated that no prior-authorization was necessary in 22.2% of cases (n=12/54). The most frequent cited reasons for claim denial were medical record requests (n=80, 37%), non-covered charges (n=61, 28.2%), and medical necessity (n=26, 12%). Over 25% of claims were denied a twice by insurance providers. Nearly 10% of claims required tertiary appeals and one case was approved on the quaternary appeal. Distribution of denials was equally dispersed amongst claims that were in- versus out-of-network. Average claim to payment period was 45.3 days.
CONCLUSION: Even for practices following third-party payer established prior-authorization guidelines, denials for breast reduction claims are occurring at high rates creating unnecessary administrative burden. Continual advocacy is needed to reduce these inefficiencies for plastic surgery practices.
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