1010s – Proceed with Caution
By: Andres Gomez
We are seeing providers increasingly attempting to circumvent the Reimbursement Schedule with the 1010 process. It is important to be on the lookout for some of these red flags to avoid potential issues later on with the payment of the treatment:
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CPT Codes – WE are seeing more and more 1010s be submitted requesting a particular procedure and include CPT codes on the request. We have noticed that when the UR teams look at these, they look specifically at the treatment requested and, oftentimes, do not look at the CPT codes or how these play a role in said treatment. It is fairly common, particularly from providers who offer “Health Solutions”, to unbundle CPT codes, include these in the 1010, and then avail themselves on approval to contend that CPT codes that would otherwise not be payable should be paid. When you encounter these types of 1010s, it is best to approve with modifications and indicate that the procedure should be performed and billed in accordance with the Louisiana Medical Treatment Guidelines and Reimbursement Schedule. This will offer you some protection against these claims.
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Multiple Body Parts – There have been several instances where the 1010 will include multiple procedures. Often, it will include the procedure for the compensable body part first and then followed by a body part that perhaps had not been at issue before or that has been determined as non-compensable. The providers are relying on the approval or, they will often resubmit several times hoping for an inadvertent approval. If a 1010 is submitted requesting multiple procedures, request that the provider send a 1010 for each or, in the alternative, approve it with modification and indicate that only a specific body part or procedure is approved, and the others are not and will not be paid.
The relationship with the plaintiff bar and treating physicians is stronger than ever. We have all deposed doctors and see in medical records that certain recommendations are being made at the request of the attorney and not necessarily because that is what the doctor initially thought was necessary (referrals to other specialists that may not be necessary, work status changes, etc.). 1010s must be reviewed carefully for anything that may appear out of the ordinary.
