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Blog Posts by Author: Diana Richard

Pathology Denial Metrics and Implementing a Strategic Appeals Processes

Pathology practices are becoming increasingly inundated with added requirements for prior authorization and medical necessity documentation. Insurance requirements are becoming more onerous, and lines are increasingly blurred around what is required for claims to meet individual payor standards for reimbursement. Failure to meet a single requirement, on even a small percentage of claims, is...

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UHC Implements DEX Z-Code Requirements on Medicare Advantage Claims Starting June 1, 2021

this post was updated on June 1, 2021. In March 2021, United Healthcare announced an updated policy for Medicare Advantage plans, whereas they will be requiring providers to include the appropriate DEX Z-Code identifier on claims beginning June 1, 2021. United Healthcare has announced this policy update has been delayed and will not be implemented on June 1, 2021. Further communication will be...

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Temporary Claims Hold Pending Congressional Action to Extend 2% Sequester Reduction Suspension

In anticipation of possible Congressional action to extend the 2% sequester reduction suspension, CMS has instructed the Medicare Administrative Contractors (MACs) to temporarily hold all claims with dates of service on or after April 1, 2021. Per CMS’s announcement, this is intended to only take place for a short period of time and should not have any significant impact to providers’ cash flow....

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The Remaining 20%: The Critical Role Appeals Play in Profitability (Part 2)

This blog post is part two of the series. View Part One. View Part Three. The first installment of this three part series provides data on denial trends in the pathology, molecular, and the clinical laboratory marketplace. Understanding root causes for specific denials enables us to initiate a strategic, multi-tiered approach to appeals. Measuring outcomes on all attempts to recover revenue,...

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The Remaining 20%: The Critical Role Denials Play in Lost Revenue (Part 1)

This blog post is part one of the series. View Part Two. View Part Three. In revenue cycle management we’ve always been of the mindset that 60-80% of billing is clean when the order is received and relatively simple to do well; however, it is how the remaining percentage is tackled that will determine whether your efforts are truly successful. That could never be truer than with the climate we...

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UHC Announces Designated Diagnostic Provider Requirements for Coverage

On February 24, 2021, XIFIN learned that UHC has delayed the application deadline from February 28, 2021 to March 10, 2021. The go-live date of July 1, 2021 is still in place. Additional requests to confirm how places of service 81, 11, 19, 22 are impacted has been requested from UHC. XIFIN will provide additional updates as they are received. UHC recently announced plans to implement the...

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Automation of Prior Authorizations and Appeals is Possible and Key to Reducing Costs

Many issues are challenging diagnostic providers’ ability to maximize payor reimbursements, such as the significant increase in required prior authorizations (PAs) and the high cost of appeals.These issues are even more difficult for laboratories and remote patient monitoring device companies using traditional billing systems that have few or no automation tools. Hospital outreach programs and...

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UHC Suspends Prior Auth Requirements for Trichomonas & Candida, Will Adopt CMS Billing Policy for Prostates on January 1, 2021

Suspension of Trichomonas and Candida Prior Auth Requirements Beginning Oct. 1, 2020, for all commercial and UnitedHealthcare Community Plan plans included in the genetic and molecular testing program, UHC will be suspending prior authorization and notification requirements for the following three genetic and molecular CPT codes performed in an outpatient setting: 87480: Infectious agent...

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