Update: Prior-authorization continues to cause confusion (and missed payments)

October 30, 2018

As labs and pathology groups across the nation continue to adjust to the requirements of prior-authorization programs, we’re seeing private payers who are partnering with these services experience some growing pains as well.

Earlier this year, while conducting a billing audit for a South Carolina-based pathology group, we found several accounts that were allowed at less than the anticipated reimbursement amount. When reviewing these cases with our client’s biller, we determined the issue was stemming from an apparent limit on 88305 units.

In one instance, the group billed 13 units, which were shown on the EOB, but the carrier processed the allowed amount as only six units. When questioned on this decision, the carrier responded by referencing a suggested policy from their prior-authorization partner stating prostate biopsies will be capped at six units to prevent fraud and abuse.

The issue? The carrier later clarified it had never officially adopted the policy, which means there should not have been denials related to it. Additionally, the carrier was equally confused when it discovered that despite the 13 units being submitted, only the six that were eventually paid were received by their system. The carrier was unable to explain what caused the number of units to be automatically reduced, but agreed to dig into the issue.

In the end, we identified 95 affected claims that were improperly underpaid by a total of $70,000, which the carrier agreed to pay back to our client. 

After requesting a new report be generated, we determined that 14 appears to be the maximum number of units that will be paid upon appeal. Additional units beyond that limit were subsequently underpaid. However, we’re now seeking to confirm that number with the insurance team in question.

In the meantime, the carrier has assured us that they have corrected their system to ensure we do not continue to see underpaid claims related to this issue moving forward.

If you’re experiencing similar issues, or are struggling to understand how to properly appeal medically unlikely edits, Vachette Pathology can help get you paid. Contact us today at 517-486-4262.

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