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Can Payors Recoup COVID Testing Claims During the PHE?
Ann Lambrix, VP of RCM Consulting

Ann Lambrix, VP of RCM Consulting

Ask Ann is a new revenue cycle management mailbag headed by Ann Lambrix, Vice President of RCM Consulting for Lighthouse Lab Services. Each month, Ann will be tackling the burning billing and reimbursement questions from our clinical laboratory and pathology clients. If you would like to submit a question for consideration, you may do so by emailing amitchell@vachettepathology.com.

 

Dear Ann:

Today I received a letter from an insurance company that we billed COVID tests to. The letter states “COVID-19 testing is NOT a covered benefit for asymptomatic individuals to assess health status as required by employer, school, etc.” Payer is deeming these paid COVID testing claims as overpayments. 

They are looking to recoup payment on multiple patients they have deemed “not medically necessary”. How do I respond? Is there anything I can do here? 

Signed,

Frustrated and concerned in Timbuktu.

 

Dear Frustrated and Concerned,

Get ready! If you are billing insurance for COVID patients, you will probably see more letters like this as payors begin to audit their payments of COVID testing over the last couple of years.

You can reply back to the payer reflecting any due diligence that you have done to vet patients up front. This may include any intake forms the patient is completing prior to testing, indicating any signs, symptoms, or recent exposure, and/or documentation from the ordering physician.

It would be also good to point out the following:

Due to the COVID pandemic, The Family First Coronavirus Response Act (FFCRA) and The Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law on March 18, 2020.

 

Per Section 6001 of the FFCRA:

Section 6001 requires group health plans and health insurance issuers in both the group and individual markets for health insurance to provide coverage without cost sharing or prior authorization during any portion of the COVID-19 emergency period for:

  • Any in vitro diagnostic products used for the detection and diagnosis of COVID-19 including the cost of administering the products; and
  • Any other items and services furnished to an individual during a visit for such testing (including the visit itself whether provided in-person or via telehealth).

The COVID Public Health Emergency (PHE) period has been extended and is currently set to expire July 15, 2022. Additionally, news broke earlier this week indicating the PHE will receive another extension beyond the current deadline, although HHS has yet to make an official announcement.

The FFCRA also prohibits plans and issuers from imposing medical management, including specific medical screening criteria, on coverage of COVID-19 diagnostic testing. Plans and issuers cannot require the presence of symptoms or a recent known or suspected exposure, or otherwise impose medical screening criteria on coverage of tests.

In summary, when an individual seeks and receives a COVID diagnostic test from a licensed or authorized health care provider, or when a licensed or authorized health care provider refers an individual for a COVID diagnostic test, plans and issuers generally must assume that the receipt of the test reflects an “individualized clinical assessment”, and the test should be covered without cost sharing, prior authorization, or other medical management requirements.

F&C, hopefully you have some good documentation to support your charges and keep your payment. Unfortunately, the burden of proof will need to be on the submitting provider.

Sincerely,

Ann Lambrix

 

If you need assistance navigating recoupment requests or appealing COVID testing claim denials, don’t hesitate to contact our team for a free consultation.

 

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