By Angela Mattioda, Vice President of Revenue Cycle Management
When the out-of-network model was more commonplace in the ASC industry,
ASCs often needed to appeal claims to receive additional payment after
being paid typically 70% of what they expected in the initial payment.
When the industry started moving toward a more heavily in-network environment,
appeals became less common because most payers paid per their contracted rates.
However, over the years, payers have found more and more ways to discourage
ASCs from obtaining what is contractually owed to them. We now consider
these challenges to be part of “the game” in revenue cycle
management. To give yourself more of a fighting chance in this game, there
are a few steps to take during the insurance verification and authorization
process that may help you avoid denials and the need to submit appeals.
Most payer portals and fee schedules will provide a list of CPT codes that
require authorization. It’s advisable for an ASC's insurance
verification staff to have these lists readily accessible. It’s
routine to be told by a payer that an authorization isn’t required
when, in fact, it is. Failure to submit a claim without the required authorization
may result in a denial.
Authorizing a range of codes can be a great way to avoid denials. The most
common procedures where a range of codes would be applicable are GI procedures
— upper GI (43235–43270) and lower GI (45378 — 45398)
and orthopedics procedures — knee arthroscopy (29870–29889).
Unfortunately, it’s becoming increasingly difficult to get payers
to agree to authorize a range of codes. I highly recommend not taking
no for an answer and escalating the issue until you run out of options.
Why? For some cases, it’s extremely difficult to determine if the
CPT code will change from the scheduled code to the final code.
If, despite your best efforts, you are unsuccessful in getting a range
of codes authorized, another tactic is to track the scheduled codes versus
final coding to determine what cases tend to experience the most coding
discrepancies and then track the denials for those cases. It may be possible
to have your surgeons schedule the most common code per the final coding
data for future cases to help avoid a repeat of issues.
Another tip is to ensure you have the clinical policy requirements that
identify medical necessity requirements. These are published on payer
websites. Your surgeons should be familiar with these requirements.
When submitting an appeal, individualize the appeal to the patient and
case. It’s okay to develop standardized templates, but the appeal
itself should be specific to the patient and denial reason(s). If you
receive an erroneous denial due to authorization, confirm the authorized
date range and CPT code and provide the authorization number and any reference
contact information to the payer. Be sure claims submitted include the
authorization number to avoid as many erroneous denials as possible.
When appealing for medical necessity, do your due diligence in understanding
the clinical policy requirements and determine if the procedure met the
medical necessity requirements. Begin the appeal by stating that all requirements
were met per the clinical policy and include the document number. You
will then want to detail the requirements that were met and attach the
operative report and history and physical. It might also be necessary
to include nurse notes and radiology pictures if those records help support
If you contract with Blue Cross Blue Shield (BCBS), here's an important
tip. BCBS has partnered with AIM Specialty Health as a benefits management
partner. AIM has a provider portal that can be used to request prior authorization, which is
accessible here. When verifying benefits with BCBS, it’s imperative that you confirm
if the group plan is participating with AIM Specialty Health. You can
obtain an authorization from BCBS, but if you don’t also receive
the authorization from AIM, it’s extremely difficult to fight the
denial or the 50% penalty that may be assessed.
If you are unsuccessful in appeals, you can consider escalating the claim
by appealing to your state's department of insurance. If you failed
to meet clinical policy requirements, the appeal likely will not come
back as successful. If the surgeon feels strongly that medical necessity
requirements were met, it’s recommended that you request a peer-to-peer
review with the payer before escalating to the state level.