Medical Mutual of Ohio Denials on IHC

October 21, 2014

By Jessica Jankowski, Executive Client Administrator

Once again we find another carrier creating a policy reflective of the Local Coverage Determination (LCD) that was published recently by WPS Medicare.

Medical Mutual of Ohio (MMO) created a policy effective July 2014 that tied the 88342 code to Lynch Syndrome tumor testing, thus requiring a prior authorization for any 88342 that comes through their door for processing.

While the 88342 is indeed one code that could be used in Lynch Syndrome testing, it is certainly not exclusive to this.  Once these denials were detected, we promptly connected with a representative from MMO to review some of our claims, inclusive of pathology reports, so that they could see how these 88342 codes were being utilized.

Roughly a month later, they rescinded the policy.  However, in order to get any claims paid, we needed to submit a “claims project” (fancy lingo for a spreadsheet with vital claim information) for MMO to reprocess the claims they originally denied.  We were informed by MMO that this would be the only way to ensure payment on these claims (Medical Mutual , 2014).

Take-aways:

1). Pay close attention to your denials.  Is your biller providing you with detail of your denials monthly?  This is a great way to spot any denial trends.

2). Be sure your biller can trace back all claims that were denied AND provide reporting on payment for these claims to ensure the process has been complete.

References
Medical Mutual (2014, June ). Retrieved July 2014, from Medcal Mutual Medical Policies: https://www.medmutual.com/provider/MedPolicies

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