As some areas see an uptick in post-procedure claim denials from payers, ASCs may be at a loss on how to salvage payments.
Becker's connected with Amy Chamberlin, BSN, RN, nurse care manager and clinical denials specialist at Binghamton, N.Y.-based United Health Services Hospitals, to find out what can be done when faced with post-procedure denials.
Editor's note: Response has been edited lightly for length and clarity.
Question: What should be done when payers deny procedures?
Amy Chamberlin: I can see post-procedure denials for multiple reasons. One being no authorization, which could be for multiple reasons, such as simply neglecting to get prior authorization, getting authorization for the wrong CPT codes or in a situation when you previously got authorization, but the procedure was changed in the OR due to complications or new findings.
Another could be the procedure being deemed not medically necessary. On review of the medical record, the payer determined the policy/criteria for the procedure was not met.
The payer also could have denied a procedure as experimental/investigational. I generally see this with newer, more expensive procedures/products. Often when the provider will attempt to get prior authorization, they will be incorrectly told authorization is not needed. In these cases, where a procedure or product is considered experimental or investigational there often won't be any circumstances where it would be covered, therefore it would never need prior authorization. It has been a challenge to try and explain this to provider offices, especially nonclinical staff who handle authorizations.
Less common would be for a facility or provider who was out of network with the payer. These denials are most likely to be a post-claim denial. The first step in any of these is usually a reconsideration, or a first-level appeal. Some payers have started refusing to review no authorization denials for medical necessity. Depending on the payer, there may be a second level of internal appeal available. With commercial and Medicare payers in New York state we have the option of external appeals to the Department of Financial Services for medical necessity and experimental/investigational denials.
When I get a denial, I review it to see what the denial reason is. Sometimes, there is an easy fix. Maybe the claim went out without the authorization number. I am not a coder, but I take a look at the coding to see if it looks right. I compare it to what we had authorization for, what is on the OR consent and operation report. I have caught some coding errors, and once corrected, that took care of the denial. I check to see if it is denied due to the wrong status — inpatient versus office-based surgery. If it is denied for medical necessity or due to being experimental/investigational, I will review the relevant medical policy before starting the appeal process.