Nephrology billing and accounts receivable

Nephrology bills the month, not the visit. The monthly dialysis management service is one claim per patient per month, and what it is worth depends on where the patient was treated, how many face-to-face visits are documented, and how many days of the month the practice actually managed that patient. It gets reconciled against the unit's treatment log before it goes out.

Where the money leaks in nephrology

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.

• Monthly dialysis management billed at a visit tier the flowsheets do not support, because nobody counted the documented face-to-face visits before the claim went out
• The managing nephrologist changes mid-month, both practices bill the whole month, and the second one denies as a duplicate when the month should have been split into per-day services
• Inpatient days not carved out of the month, so the full-month outpatient service is billed instead of per-day services for the days the patient was managed as an outpatient
• Home dialysis training billed with no training log naming who was trained, on what dates, over how many sessions, and whether the patient or caregiver completed the course
• Access-circuit imaging billed with an angioplasty of the same circuit in the same session and denied as included in the intervention, with no note supporting a separate diagnostic study
• The dialysis unit's census arrives weeks late and is never reconciled against the treatment log, so patients who were seen and documented are never billed at all

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 nephrology, 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-252 — Additional documentation required
  The payer will not decide until it sees paperwork. Nothing happens until it arrives.
  Recovered by being answered with the document the payer names. Matched from: “Access-circuit imaging billed with an angioplasty of the same circuit in the same session and denied as included in the intervention, with no note supporting a separate diagnostic study”
• 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: “The dialysis unit's census arrives weeks late and is never reconciled against the treatment log, so patients who were seen and documented are never billed at all”

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

Questions