(p. A13) I recently operated on a child with strabismus (crossed eyes). This child was covered by Medicaid. I was required to obtain surgical pre-authorization using a Current Procedural Terminology, or CPT, code for medical identification and billing purposes. The CPT code identified the particular procedure to be performed. Medicaid approved my surgical plan, and the surgery was scheduled.
During the surgery, I discovered the need to change my plan to accommodate findings resulting from a previous surgery by another physician. Armed with new information, I chose to operate on different muscles from the ones noted on the pre-approved plan. The revised surgery was successful, and the patient obtained straight eyes.
However, because I filed for payment using the different CPT code for the surgery I actually performed, Medicaid was not willing to adjust its protocol. The government denied all payment. Ironically, the code-listed payment for the procedure I ultimately performed was an amount 40% less than the amount approved for the initially authorized surgery. For over a year, I challenged Medicaid about its decision to deny payment. I wrote numerous letters and spoke to many Medicaid employees explaining the predicament. Eventually I gave up fighting what had obviously become a losing battle.
For the full commentary, see:
ZANE F. POLLARD. “The Bureaucrat Sitting on Your Doctor’s Shoulder; When I’m operating on a child, I shouldn’t have to wonder if Medicaid will OK a change in the surgical plan..” The Wall Street Journal (Thurs., May 22, 2014): A13.
(Note: the online version of the commentary has the date May 21, 2014.)