By Susan Gatehouse, RHIT, CCS, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer ​

In late 2020, the Centers for Medicare & Medicaid Services (CMS) announced that it would begin covering a substantial portion of the cost of implantable heart failure devices for treating chronic heart failure. These devices are designed to treat patients by electrically activating the baroreflex, the body’s natural mechanism for regulating cardiovascular function.
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The initial announcement stated that Medicare would pay for up to 65 percent of the device cost for the next three years. CMS also noted it would cover the device’s implant procedure costs. Thus, any facility performing these procedures today is looking at a significant reimbursement (and potential claim risk, if not properly processed). The 2022 national APC (Ambulatory Payment Classifications) payment rate (Medicare reimbursement under the Outpatient Prospective Payment System, or OPPS) is $30,063.48.

The average cost of debunking a denial is $25 per claim, not to mention the continuous challenges associated with attaining timely payment. Reviewing denial management strategies on a regular basis may prove a more efficient payment journey.
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Claim denials are a continuous challenge for the healthcare industry, as providers struggle with write-offs and the resources needed to manage them. Indeed, a well-thought-out strategy will improve claims’ financial performance; however, as the causes for denials continue to evolve in complexity, the strategy to combat denials should continually be assessed and transformed in order to remain effective. To ensure accurate payment from payers, providers need a strategy that addresses denials with a current, all-encompassing approach.

With a monthly barrage of claim denials, examining the root causes of delayed or non-occurring payment leaves an organization exposed to ongoing denials that could be remediated.