Allergy and Clinical Immunology billing and accounts receivable

Allergy practices bill testing and immunotherapy against strict unit and frequency rules, and the antigen preparation is billed separately from its administration.

Where the money leaks in allergy and clinical immunology

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Percutaneous and intradermal test units exceeding the payer's per-session limit
• Antigen preparation billed without the matching injection administration
• Immunotherapy vials billed by dose when the payer pays by vial, or the reverse
• Biologic therapy denied for prior authorization or step therapy not completed
• Testing denied as not medically necessary for the diagnosis submitted

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working allergy and clinical immunology, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-16 — Claim lacks information
  Something on the claim is missing or malformed. On its own the code tells you nothing — the detail is in the remark code that comes with it.
  Recovered by being corrected and resubmitted. Matched from: “Percutaneous and intradermal test units exceeding the payer's per-session limit”
• CO-197 — Prior authorization absent
  The payer required prior authorization for this service and cannot find one attached to the claim.
  Recovered by being taken back to the authorization. Matched from: “Biologic therapy denied for prior authorization or step therapy not completed”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a allergy and clinical immunology AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions