Overpayment Recovery for Multiple Surgical Procedures
Posted February 24, 2021
On June 1, 2021, Blue Cross and Blue Shield of Illinois (BCBSIL) will begin additional reviews of claims after payment to make sure they adhere to our reimbursement policy for multiple surgical procedures.
Key Point: Our payment policy states that when multiple procedures are performed by the same physician or physician group on the same patient in the same operative session, only the primary procedure will pay 100% of the allowed amount. Secondary or subsequent procedures will pay at 50%.
If you submit claims with multiple billable units of the same procedure, for the same member, on the same date of service, at the same location, you may be paid 100% for each procedure, despite our current payment policy. However, claims with dates of service on and after June 1, 2021, will be processed consistent with our payment policy. Some procedures may be exempt from this policy and pay 100% of the allowed amount.
What this means: If we overpay you, we’ll recoup the amount overpaid against future claims. This could also impact member cost-share, so you may need to reimburse members.
Multiple Surgical Procedure Guidelines
- Primary procedure: The surgical procedure with the highest allowed amount is the primary procedure. If two procedures have the same allowed amount, only one will be considered primary. Other procedures are secondary or subsequent. The primary procedure will be reimbursed 100% of the allowed amount.
- Secondary procedures: Secondary procedures will be reimbursed 50% of the allowed amount.
- Bilateral procedures: If the surgical procedure for either side is the highest allowed amount, then one procedure will pay at 100% and the second at 50%, all other secondary procedures will also be reimbursed at 50%. If at least one other surgical procedure is the highest allowed amount, then the bilateral procedure (both sides combined) will be reimbursed at 75% and all other secondary procedures will be reimbursed at 50%.
Exclusions: Claims for members with the following benefit plans are excluded from this policy:
- BCBSIL is the secondary payer
- Medicare Supplement
- HMO plans: Blue Advantage HMOSM, Blue Cross Medicare Advantage (HMO)SM, Blue FocusCareSM, Blue Precision HMOSM, BlueCare DirectSM, HMO Illinois®
More information: If you have any questions, please call the number on the back of the member’s ID card or contact your BCBSIL Provider Network Consultant (PNC).