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Overpayment Recovery for Multiple Surgical Procedures

February 24, 2021

Blue Cross and Blue Shield of Oklahoma has identified the need to review claims and past payments for multiple surgical procedures, to ensure alignment with our applicable reimbursement policy.

Reminder: Our payment policy states that when multiple procedures are performed by the same physician or physician group on the same patient at the same operative session, only the primary procedure will pay at 100% of the allowed amount. Please see our Clinical payment and coding policy titled Multiple Surgical Procedures Policy Number: CPCP015 PDF Document for further details. This policy also states multiple procedures should be submitted on a single claim.

What this means: If we overpaid you, we’ll request a refund and may recoup the amount overpaid against future claims according to the provisions of your provider agreement. This could also impact member cost-share, so you may need to reimburse members. You will receive an updated provider claim summary with the adjudication details that include the new patient share.

Reimbursement Details: When two or more surgical procedures are performed on the same date of service by the same professional provider, the following pricing methodology is used:

  • Primary Procedure: Eligible at 100% of the fee schedule or billed amount, whichever is less
  • Secondary and Subsequent Procedures: Eligible at 50% of the fee schedule or billed amount, whichever is less

Bilateral procedures: If the procedure for either side is the highest allowed amount then one procedure will pay at 100% and the second at 50%, all secondary procedures will be reimbursed at 50%. If another procedure is the highest allowed amount, then the bilateral procedure (both sides combined) will be reimbursed at 75% and all secondary procedures will be reimbursed at 50%.

Claims involved: To be considered for multiple surgical procedure reductions, these services must be performed:

  • on the same date of service,
  • within the same operative session,
  • by the same provider, and
  • at the same place of treatment.

Exclusions: Claims for members with Medicare benefit plans are excluded from this policy.

More information: If you have any questions, please call the number on the back of the member’s ID card or call the Provider Contract Support Unit at 800-722-3730, Option 2.