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Anesthesia Payment Options for Non-Covered Services

February 27, 2024

As payer policies evolve, once-covered services often become non-covered services. The two most common examples of this are colonoscopy (depending on the patient’s physical status) and anesthesia for Chronic Pain Injections (such as epidural steroid injections, facet injections and transforaminal epidural steroid injections).

A number of notable insurance plans have stopped paying for anesthesia in colonoscopy cases where the ASA physical status is I or II and other patient-specific variables. As to anesthesia for chronic pain injections, the problem is that the CPT codes for the injections are intended to cover the cost of normal analgesia; thus, it would be necessary to demonstrate the need for anesthesia. The result of all this can be some very frustrating denials.

Physicians do not like to provide valuable services for which they are not going to be paid. Hence the question: what should one do? Obviously, one option is to stop providing the service, but this is not the preferred option when the provider believes the service would be beneficial to the patient. The good news is there are other alternatives to consider, although these do not guarantee success.

Picking the Right Form

One option is to implement a form called an Advanced Beneficiary Notice (ABN), which is specifically intended to advise patients that certain services might not be reimbursed by Medicare. Financial responsibility would devolve to the patient alone if the claim is denied. The ABN gives the patient the option of not having the service or having it but knowing that he or she is responsible for payment. The most significant aspect of the ABN is that it is only for Medicare patients. The form does not apply to commercial insurance.

For non-Medicare patients, the concept is the same, but the specifics are more complicated. Many commercial insurers have their own waiver of liability form. Each plan must be contacted for specific policy guidelines and an appropriate form to use. These forms are often quite detailed and must be completed for the specific procedure being performed. There must be a discussion with the patient so that he or she is aware of the financial responsibility to be incurred. Both the provider and the patient must complete and sign their portion of the form.

The Practical Challenges

When an anesthesia practice decides to implement either type of form, the providers and the site must be prepared. Forms need to be available. Providers must understand their responsibility. Providers should also understand that ABN forms and waiver of liability forms are not to be utilized for every single patient based on procedure type, but rather when it is identified that the specific patient’s coverage might not reimburse the service. It is essential that the forms get to the billing office. A tracking mechanism must be established by the provider to ensure forms are received for all the categories of service defined by the practice, where applicable. It will also be necessary for providers to perform regular Q&A to ensure that the forms are completed as per the payer requirements.

Again, these forms are a kind of provisional notice that the insurance is unlikely to pay for the service. When the insurance does not pay the claim, the responsibility shifts to the patient. If the patient cannot or will not pay the bill, the practice has little leverage to exact payment.

Our Experience

As a practical matter, it is impossible to know how effective the use of ABNs and other waivers of liability actually are. If the ultimate objective is to get paid for the service rendered, here are numerous factors to consider. Sometimes, payers just pay the claim. Sometimes, the fact of having discussed the value of the service with the patient is all the motivation needed for the patient to assume responsibility for payment should the service ultimately be denied. And, sometimes, there are simply complicating factors that make payment unlikely.

Do you need ABNs for your practice?

As usual, the answer is “that depends.” ABNs and waiver of liability forms are potentially valuable tools if they are implemented appropriately. It is always best to evaluate the need before implementing a new procedure that complicates the documentation of care.

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