We have a few insurance companies denying outliers based on supplies charges (rev) codes. How do we determine what rev codes / supplies should not be on the inpatient itemized bill. Any suggestions on how to appeal these?
We have been fighting these for many months now. The payers are drafting policies to allow them to accuse us of unbundling our charges. We had success with Cigna on many of our claims because they were outliers and we had contract language that did not allow them to exclude charges from the outlier calculation separately from the approved and paid DRG portion of the claim. It was a lengthy battle for the contracting team and has taken months to collect back reimbursement owed. I believe it also helped that our contract contained language that policy changes that have an egregious impact on expected revenue per the agreed contract have to be sent, reviewed and approved by providers within a 60 day window prior to their implementing such a policy. We now have to set our sites on Kaiser Permanente as they have established a National Review process for outlier claims and are attempting to reduce payments based on these reviews.