Are Primary Care Claim Denials Increasing Revenue Loss?

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Yes,  primary care claim denials are increasingly contributing to revenue loss for physician practices by delaying reimbursements, increasing administrative workload, and weakening overall revenue integrity. As payer scrutiny intensifies and documentation requirements expand, primary care practices across the country are seeing a measurable rise in denial rates that directly affect operational stability and financial outcomes. Primary care providers operate on high patient volumes and relatively thin margins. When denials increase—even slightly—the cumulative impact can significantly reduce collections and ultimately affect a practice’s ability to yield EBITDA . Understanding why these denials occur and how to prevent them is essential for maintaining a healthy revenue cycle. The Growing Impact of Primary Care Claim Denials In recent years, payers have strengthened claim review processes, automated adjudication systems, and documentation requirements. These changes have led to...
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Prior Authorization Exemption for Certain DMEPOS Items

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On 4th April 2022, CMS published a rule on “suspension of prior authorization requirements for orthoses prescribed and furnished urgently or under special circumstances”. Prior authorization helps Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers ensure that applicable Medicare coverage, payment, and coding rules are met before DMEPOS items are delivered. The prior authorization program helps to protect the Medicare Trust Fund from improper payments while ensuring that beneficiaries can receive the DMEPOS items they need in a timely manner.

CMS maintains a master list of DMEPOS items that requires either a face-to-face encounter and written order or prior authorization requirements. You will find the updated list here. Due to the need for certain patients to receive an orthoses item that may otherwise be subject to prior authorization when the two-day expedited review would delay care and risk the health or life of the beneficiary, CMS suspended prior authorization requirements for HCPCS codes L0648, L0650, L1832, L1833, and L1851 furnished under following circumstances:

  • Claims for these HCPCS codes that are billed using modifier ST will not undergo prior authorization and will instead be subject to 100% prepayment review.
  • For suppliers furnishing these items under a competitive bidding program exception (as described in 42 CFR 414.404(b)), claims billed with modifiers KV, J5, or J4 would convey that the DMEPOS item is needed immediately and therefore these modifiers will be accepted in addition to the ST modifier. Ten percent of claims submitted using the KV, J5, or J4 modifiers for HCPCS L0648, L0650, L1833, and L1851 will be subject to prepayment review.
Prior authorization helps DMEPOS suppliers ensure that applicable Medicare coverage, payment, and coding rules are met before DMEPOS items are delivered. MBC can help you to receive accurate insurance reimbursements for DME items including prior authorizations, Read Here: https://bit.ly/3Mow0ZZ. To know about our DME billing services, Contact us at info@ medicalbillersandcoders.com/ 888-357-3226
Location: United States

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