Endocrinology and Diabetes billing and accounts receivable

Endocrinology lives on continuous glucose monitors, insulin pumps and diabetes education — three benefit categories with different rules, and often three different places a claim can be sent.

Where the money leaks in endocrinology and diabetes

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.

• Continuous glucose monitor denied for coverage criteria the chart does not evidence
• Pump supplies billed under the medical benefit when the plan carves them to pharmacy
• Diabetes self-management education billed without the required referral or accreditation
• Frequency limits exceeded on monitoring tests within a rolling year
• Obesity and weight-management drugs denied under a plan exclusion rather than medical necessity

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 endocrinology and diabetes, 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-50 — Not deemed medically necessary
  The payer does not accept that the documentation supports the service. This is a clinical argument, not a clerical one.
  Recovered by being appealed with clinical documentation. Matched from: “Continuous glucose monitor denied for coverage criteria the chart does not evidence”
• CO-22 — May be covered by another payer
  The payer thinks somebody else is primary. Until coordination of benefits is corrected on their file, nothing on this claim will pay.
  Recovered by being fixed at coordination of benefits and rebilled. Matched from: “Continuous glucose monitor denied for coverage criteria the chart does not evidence”
• CO-151 — Too many services billed
  The payer accepts the service but not the quantity or the frequency at which it was billed.
  Recovered by being appealed with clinical documentation. Matched from: “Obesity and weight-management drugs denied under a plan exclusion rather than medical necessity”

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 endocrinology and diabetes AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions