We’ve recently seen many commercial payers move to only paying prostate biopsies coded G0416 instead of 88305 (for instance, Cigna will institute this rule effective Aug. 18). It’s not exactly a major surprise to see them adopting CMS guidelines on this issue.
However, several clients recently informed us UnitedHealthcare (UHC) has issued refund requests to recover 88305 payments for prostate biopsies performed on Medicare Advantage members throughout the past six months, despite the payer not previously issuing any communication about this change.
When questioned, UHC responded that their policy for prostate biopsies to be billed with G0416 has been in effect since January 2015. While this change is in line with Medicare policy, UHC had continued to pay prostate biopsies billed with 88305 until this recent communication.
If you receive a similar notice, we recommend reviewing your contracts for communication and recoupment policies to understand whether you have leverage to push back. As we continue to explore options for our clients, let us know if you’re also being impacted by this aggressive take-back.