Friday, July 01, 2016 03:05 PM

3D Mammography - Breast Tomosynthesis payer denials: A strategy to secure reimbursement

You have a right to be paid for providing service!

Providers of 3D Mammography/Breast Tomosynthesis are flooding the Department of Managed Health Care (DMHC) with requests for Independent Medical Reviews (IMRs). DMHC has received over 400 IMR requests per week. Currently they have about 325 decisions.  90% of IMRs filed have been overturned and claims paid by the insurer.

Below is a link to CA AB bill No. 2764, which states in part, “Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of its provisions a crime. Existing law provides for the licensure and regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts, except specialized health care service plan contracts, and certain health insurance policies to provide coverage for mammography for screening and diagnostic purposes.

This bill would require the mammography coverage to include, but not be limited to, digital mammography and breast tomosynthesis. Because a willful violation of the bill’s requirements relative to health care service plans would be a crime, the bill would impose a state-mandated local program.”

Attached are 1) the DMHC IMR Form/authorization form and 2) a letter that some Breast Tomosynthesis providers in California aresubmitting with the DMHC form requesting an Independent Medical Review/complaint to the Department of Managed Health Care. An IMR can be completed on line by accessing the DMHC website at:www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForm.aspx   A Spanish version can be found on this link as well.

There is something else that would help ensure passage of CA AB bill No. 2764 -- draft a letter to your California Assemblyperson singed by the radiologists, hospital administrators, and/or practice leadership.  Find your representative at http://assembly.ca.gov/assemblymembers 

You can send your correspondence electronically or on paper. You can invite them to your hospital or imaging center for a tour and high-level clinical education about the value of breast tomosynthesis.  DO THIS SOON!!!

Source: Brigette LaBar, President, California Chapter - Radiology Business Management Association (RBMA)