Three Reasons Vascular OBL Claims are Denied
Vascular procedures are becoming more and more common in office-based labs (OBLs) rather than in hospitals, thanks to technology improvements and Medicare changes. To effectively bill for these procedures, you need to do three things.
- Let payers know that the procedure is truly medically necessary.
- Document the procedure with a detailed roadmap.
- Keep authorizations organized.
In an ideal world, following those steps would mean smooth sailing for your claims. Unfortunately though, just because something should go smoothly, doesn’t mean it will. Often, like our veins, billing claims can get blocked. Here are three reasons vascular OBL claims are denied, and tips for keeping the billing process flowing smoothly.
1. Unclear Medical Necessity
Often, payers deny claims or flag claims for more documentation if they suspect that a procedure is cosmetic, not medically necessary. Varicose veins are a good example: many people have cosmetic surgery for Varicose veins, but Varicose veins can also lead to pain and complications that do require medically necessary interventions.
Each payer has slightly different patterns for which claims they will deny. Often, denials are flagged based on specific combinations of billing codes. For example, we’ve found that some payers flag claims any time Varicose veins are coded. Without coding Varicose veins, the same procedure for the same complication would sail through.
Paying attention to which payers flag which claims can help you identify patterns over time. Gentem builds that kind of analysis into our process across customers, so we can help you learn from broader trends.
Still, some denials are inevitable; it pays to be ready. Often, payers will request a letter of medical necessity signed by the physician. Having that letter countersigned by the patient is also a good idea. That step lets the payer know that the patient discussed the procedure and confirmed medically necessary.
One way to stay ahead of possible denials is to have that letter signed and countersigned before the claim is even filed. That way, the biller can have it ready to submit as soon as a denial comes through.
2. Gaps in Documentation
Payers are looking to make sure that procedures follow a clear standard of care, and that conservative practices were followed. They want a narrative that explains exactly what happened and in what order so someone who wasn’t there can visualize each step.
Some software tools provide a simple template where physicians can click to fill in which procedures they did in which order. For many payers though, this will not be enough. Think of documentation like a roadmap. On a cross-country trip, it’s not enough to see an outline of the states. You will need a clear route with highways, exit numbers, and rest stops.
Before submitting, check to make sure the documentation provides a clear enough route that someone else could duplicate the procedure.
3. Missing Authorizations
Often, what seems like a single procedure from the patient’s perspective is actually a whole pile of different authorizations on the payer’s end. That’s because each step must be authorized separately.
If the procedure is being repeated on the other side of the body, those are all separate authorizations too. Then, to make things more complicated, payers have strict limits on how many steps can happen in one day, so patients often come back for follow up procedures.
Clearly, getting authorizations for vascular work is a detail-oriented process. Once you figure out which authorizations you will need, it can be tempting to package them all together and request everything at once, as soon as the first procedure is scheduled.
Surprisingly, this efficiency can itself be a reason for a denial. Payers want to know that the authorizations you are requesting are truly up to date with the patient’s current needs. Sometimes, too many authorization requests at once l can result in denials and delays if the proper authorization is not added to the claim.
Instead, consider scheduling authorization requests in smaller chunks. This approach takes a little more effort in that you have to remember to follow up, but it can also save time in the long run.
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