Compliance issues, MUE denials and more in Vachette’s 2018 audit roundup

October 1, 2018

As we’ve continued to perform audits for new clients this year, Vachette’s audit team has been hard at work uncovering and correcting a host of billing and compliance issues in an effort to put missing revenue back in pockets of the labs and groups we represent. Below is a sample of some of our top audit finds of 2018 so far.

No Payments for Anatomic Pathology?

Recently, we have found that some payers are pushing contracts with no AP codes listed. Yes, this means they want to sign a lab and not pay for anatomic pathology! Be aware of this trend.

Lab Loses $80 Per Accession!

Imagine finding out your lab is losing $80 per accession. That’s the reality one lab is facing after our billing audit determined 12 percent of the cases we reviewed contained some CPT codes that were sitting unbilled in their interface without a dx code (which their biller is responsible for). Even worse, the affected claims are 246 days old on average!

Incorrect Modifiers Lead to Double Denials

Our team discovered a biller who was applying a 76 modifier when claims are denied for MUE and CCI edits, which results in the claim being denied by insurance companies due to an invalid modifier combo. The claims are then resent with 59 modifier and are again denied as duplicates. Instead, the biller should use a 59 modifier initially to avoid the modifier denial and send corrected claims when changing a 76 modifier to 59 to have the claim processed correctly and avoid the duplicate denial.

Outdated Charge Master Leads to Missed Revenue

A recent billing audit revealed our client’s charge master for G0402 is less than Medicare is willing to pay. Unfortunately, this resulted in a loss of $15.78 every time that charge was billed to Medicare.

Adjustments Sent to Patients Cause Compliance Issue

We found a case where our client’s contractual adjustments for a private payer were not posted when payment was posted. Instead, the balance was sent to the patient and collections!

Missing Patient Statements

Recently, we found a large national pathology and laboratory billing company which did not send patient statements out for five months for one of our clients! This is why you audit your billing!

Documentation Doesn’t Support Billing

Our billing audits give us an opportunity to remind labs that their documentation must always support the services they are billing. Case in point: A group was billing the Alcian blue/PAS special stain as both 88312 and 88313 when the documentation they were providing only covered 88313!

If you’re interested in learning more about any of our findings or our audit process in general, feel free to contact us directly at 517-486-4262. For updates on our latest finds, follow us on Facebook, Twitter and LinkedIn.

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