Wiki Destruction of AKs

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yoshi2013

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Would it be legal to treat patients AKs with fraxel, which has clinical studies showing efficacy, and bill the 17004 charge to insurance. Since the fraxel actually costs more (around $800 a treatment), pt would just agree to pay the difference that insurance will not cover. So if insurance pays $200, then patient would be responsible for the $600 difference. Would that be legal/ethical?
 
I believe this would only be legal if you were not contracted/participating with the insurance company that covers the patient. For contracted payers, you are required to accept the fee schedule they have set as payment in full and cannot collect more than the patient's cost share. I'd also add a note of caution that if you do not to represent to the payer the true amount that you require for payment in full for the service, then you could be submitting a false claim.
 
Thank you! We are in network/par with the payer but the medical claim submitted to insurance would only show charges for code 17004. We will also create an in-house cosmetic claim for the fraxel at a discounted rate to bill patient. Just want to ensure that this type of billing is acceptable.
 
I answered your private message.

Definitely not legal.

17000/17004 is for destruction of premalignant lesions by any method including laser. Because the laser costs you a lot to use and it is more than the reimbursement for the procedure, you cannot pass this extra cost onto the patient. By participating with Medicare and having contracts with the insurance carriers, you agree to accept the fee schedule for the services provided. If it costs you more to use the laser to destroy AKs that you could treat with LN2 just as effectively, you cannot get request reimbursement for the added expense from the patient. You definitely cannot pass this additional expense on to the patient as a "cosmetic service". That would be a fraudulent practice.

Find another less expensive way to treat the AKs. There are plenty that exist and are effective.
 
If I am understanding this correctly, you are wanting to bill the insurance company for a procedure, in this case a destruction, and indicate that it is medically necessary by using the diagnosis of an AK, and then for that exact same service for the exact same lesion(s) you want to direct bill the patient and represent this as not medically necessary but cosmetic?
You stated :
"We are in network/par with the payer but the medical claim submitted to insurance would only show charges for code 17004. We will also create an in-house cosmetic claim for the fraxel at a discounted rate to bill patient."
So you do understand that this cannot be a service for two entirely different reasons? You cannot tell the provider this is medically indicated but tell the patient this is cosmetic and not covered. So you can hopefully see that this has potential if not real legal issues.
 
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