Infectious Disease billing and accounts receivable

Infectious disease is consultation-heavy and drug-heavy: long courses of expensive therapy, each carrying its own authorization and its own reauthorisation nobody is counting.

Where the money leaks in infectious disease

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.

• Specialty drug authorization lapsing mid-course, so later infusions deny
• Outpatient parenteral antibiotic therapy denied for home infusion coverage rules
• Consultation codes billed to payers that require an office or inpatient E/M instead
• Time-based prolonged services billed without the time documented
• Testing denied for a diagnosis outside the coverage policy's list

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 infectious disease, 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-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: “Specialty drug authorization lapsing mid-course, so later infusions deny”
• 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: “Outpatient parenteral antibiotic therapy denied for home infusion coverage rules”
• CO-27 — Coverage had already ended
  The patient was not covered on the date of service.
  Recovered by being fixed at coordination of benefits and rebilled. Matched from: “Testing denied for a diagnosis outside the coverage policy's list”

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 infectious disease AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions