Other times, surgeons have difficulty pinpointing why payers denied coverage. Denials arrive because not all requirements were met, but the unmet requirements aren’t specified.
“Spine surgery practices often receive prior authorization for procedures on the primary procedure code alone,” says Carolyn Neumann, BME, CPC, Senior Manager, Coding & Coverage Access at Specialty Healthcare Advisers. “When the claim is submitted, a denial states only ‘experimental/investigational.’ The entire procedure is denied due to an unstated element not being covered. Forcing a detailed prior authorization, with all technologies and codes included for review, is becoming necessary to avoid this happening. Proactive, documented medical necessity and procedure details must be made available to payors and facilities.”
For additional insight from Carolyn Neumann, click here.
