We are a pharmacogenetic laboratory looking to become contracted with the payers we work with. Medical necessity is the most common denial type we see outside of out-of-network type denials. What contract language would you recommend to assist with denial prevention?
Answer: I don’t know that contract language that avoids all of these denials would be possible. You could request a general reference to using Medicare coverage as a standard just to make it the same across payers. In fast changing areas, the payer coverage policies don’t always keep pace, so you have to engage with them a lot and show them where the scientific literature is. If you can form a relationship with the medical directors at each payer, that can help. In the end, denials are costly to them too.
This question was answered by: Ruth Landé, senior vice president, patient revenues, Memorial Sloan-Kettering Cancer Center, and a member of HFMA’s Metropolitan New York Chapter.
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