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.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.