CUA successful in correcting reimbursement for Durasphere injections

Physicians may rebill denied claims

There has been confusion at National Heritage Insurance Company (NHIC) regarding the failure to reimburse physicians for injecting a permanent periurethral bulking agent called Durasphere. The CPT code for the treatment is 51715. The computers at NHIC apparently could not distinguish the use of Contigen, which requires a skin test to qualify, and Durasphere, which does not. As a result, many doctors were incorrectly denied payment because NHIC's computer could not understand the difference.

Responding to the issue, CUA Past-President, Jeffrey Kaufman, M.D. has contacted the administrators at NHIC and spent considerable time providing documentation to explain the difference. As a result of his efforts on behalf of CUA Members, Dr. Kaufman was able to obtain agreement that NHIC should have paid the doctors who were denied and assurance that the problem will be corrected so that future claims will be paid correctly.

How to get paid for denied claims
The National Heritage Insurance Company has said that the claims that were denied can be rebilled or submitted as an appeal if they are within the time frame allowed. Physicians can call the Telephone Appeal Line at 888-656-3212, or submit them in writing.

If there are any further problems, please contact the CUA by email at info@cuanet.org or by phone at 714-550-9155.