Rheumatology billing and accounts receivable

Rheumatology combines long evaluation visits for complex autoimmune disease with an in-office infusion suite, joint aspirations and injections, ultrasound guidance and bone density testing. The biologics are the hard part: the practice buys the drug, stocks it, infuses it and bills it, so one authorization or documentation gap costs the drug as well as the claim.

Where the money leaks in rheumatology

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.

• Biologic denied on step therapy because the chart never records which conventional DMARDs were tried, at what dose, for how long, and why each was stopped.
• Authorization covered a fixed number of doses at a fixed interval, then the dose was escalated or the interval shortened, so the extra units sit outside it.
• Infusion claim denied because the nursing note carries no start and stop times, so initial, sequential and additional-hour administration cannot be supported.
• The amount given and the amount discarded from a single-dose vial are not both written in the note, so the wastage cannot be billed and the practice absorbs it.
• Drug the plan routes through its specialty pharmacy benefit was bought and infused under the medical benefit instead, leaving the practice holding the vial cost.
• Joint injection or aspiration done at the same visit as the evaluation, but the note blends the two, so nothing shows the visit stood alone from the procedure.

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 rheumatology, 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: “Biologic denied on step therapy because the chart never records which conventional DMARDs were tried, at what dose, for how long, and why each was stopped.”
• 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: “Biologic denied on step therapy because the chart never records which conventional DMARDs were tried, at what dose, for how long, and why each was stopped.”
• 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: “Authorization covered a fixed number of doses at a fixed interval, then the dose was escalated or the interval shortened, so the extra units sit outside it.”
• 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: “Authorization covered a fixed number of doses at a fixed interval, then the dose was escalated or the interval shortened, so the extra units sit outside it.”
• CO-198 — Authorization limit exceeded
  An authorization exists. The problem is that you went past what it allowed — more units, more visits, or a longer date range than was approved.
  Recovered by being answered with the document the payer names. Matched from: “Infusion claim denied because the nursing note carries no start and stop times, so initial, sequential and additional-hour administration cannot be supported.”
• CO-226 — Requested information not supplied
  The payer asked you for something, and either nothing arrived or what arrived did not answer the question.
  Recovered by being answered with the document the payer names. Matched from: “The amount given and the amount discarded from a single-dose vial are not both written in the note, so the wastage cannot be billed and the practice absorbs it.”

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

Questions