88342 Optum denials: How Vachette advocates for the lab and pathology industry

September 21, 2020

The following is a case study from Vachette CEO Mick Raich:

Over the years, the team at Vachette has time and time again worked to help laboratories and pathologists create and defend revenue. Whether it was finding a payer who was under paying on a CPT code, working with payers to inform them of how their policies are punitive, or educating billers on the correct way to code and bill COVID, we have been effectively able to move the needle forward. 

The latest in our string of successes comes from working with Optum Medicare Advantage. It seems they were denying 88342-26 for needing a preauthorization as a molecular code. Tiffany Apthorpe, one of our Client Administrators, noticed these denials in one of the quarterly audits we provide and decided to rectify this issue. 

Tiffany worked to get through the administrative drama at Optum to find the right person and help them understand that 88342-26 is regularly used in instances such as diagnostic surgical pathology and that requirement of a prior authorization was illogical. It took nine phone calls and four hours of her time, followed by additional emails to the Optum contact weekly to get in touch with the Medical Director. Tiffany the connected the Medical Director with a pathologist from one of the affected practices. When they talked, they were able to agree this code does not need a prior authorization.

Because of her diligence and determination, we were able to get a large payer to change their policy on this CPT code. This is just another example of how the Vachette team works to increase revenue for not only our clients, but the entire industry.

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