During a recent audit for one of my clients, I was working through some random CMS denials and
noticed that several special stains had been denied. There were eight units billed and ALL had been
denied by CMS and adjusted by the biller. Yet I know that the CMS National Coverage Determination
(NCD) allows billing for one unit - why was that unit not approved?
I spoke with the billing agency and was informed that CMS will typically deny ALL charges - even if one
should be approved - until the appeal is made. If the documentation supports the additional units,
then CMS will make payment on all the unit(s).
Typically, when a biller receives a denial letter from CMS, they begin to step through the five levels of
appeal, starting with Redetermination. The biller sends copies of supporting documentation for the
denied CPT code(s), and if the documentation supports medical necessity, CMS will make payment. If
not, the denial is upheld, and the biller will move on to the next level of appeal, Reconsideration, and so
on down the line until the claim is paid, or all levels of appeal have been exhausted.
There is one key factor to the CMS appeals process - the initial Redetermination request must be filed
within 120 days of the initial denial.
The denials I reviewed were from December 2013. The review date was May 16, 2014. The billing agency
failed to appeal the denied charges within the allotted 120 days. At this point, we've lost out not only on
getting paid for all units billed, but also on getting paid for the one allowed unit.
While these denials are for CMS, imagine how many denials this billing agency receives for the rest of the
insurance carriers. What are each carrier's appeal rules? Have we missed any other filing
limits for the appeal process? How much money is lying on the table right now?
Who's watching your denials? If you do not regularly review and discuss denial reporting with your
billing agency, you will lose revenue. The billing agency should be able to provide feedback and
information regarding the denials they are receiving from all insurance carriers they bill.
Michelle Miller is the Vice President of Vachette Pathology and Stark Medical Auditing. Our company specializes in auditing billing for hospitals, independent testing facilities, and hospital-based providers. Visit our websites: www.vachettepathology.com and www.starkmedicalauditing.com. Our direct line is 866.407.0763.
End of Management of Pathology Practices > Are You Losing Revenue from Improperly Handled Denials?