Manage Denials and Appeals for Your Clinical Lab or Pathology Practice

By Bob Croce

For The Executive War College

Dealing with claims denials is an ongoing dilemma for clinical labs and pathology practices. Not only are the number of denials by payers increasing, but the demand for additional documentation is motivating labs to re-think their entire coding, billing and collections workflows.

Are payers really worrying about more massive fraud, especially in the post Theranos era? Well, it’s more likely that the increase in denials is about payers being concerned more with unintentional coding mistakes, which are far more common than the antics of fraudsters such as Elizabeth Homes.

This is why we’ve added the session “Latest Trends in Managing Denials and Appeals of Clinical Lab and Pathology Claims” to the agenda at the 29th Executive War College. Our speakers for the session include a pair of revenue cycle management experts from XIFIN with Stephanie Denham, Associate Vice President of RCM and Analytics sharing the podium with Diana Richard, Senior Director, Pathology and Strategic Development.

Diana Richard, 
Senior Director, Pathology and Strategic Development at XIFIN

Stephanie Denham,
Associate Vice President of RCM and Analytics at XIFIN

To help labs better understand why payers deny certain claims, Richard presented an internal study during a Dark Daily webinar last spring that analyzed more than 25 million claims from the company’s client database of 2021 transactions.

The study included information about common reasons for claim denials, with breakdowns for the clinical laboratory, molecular laboratory, and anatomic pathology practices within XIFIN’s clientele.

“The most effective way to maintain manageable accounts receivable and improve the propensity to pay is to proactively capture cases at risk of denial before the claim is ever submitted,” Richard said during the webinar. “Denials will never go away, but XIFIN devotes focused effort to strategically develop ways, at the front end, to mitigate that as much as possible.”

Richard noted during the webinar that the top reasons for denials included the following codes:

  • CO151—The payer believes the information submitted does not support this many/frequency of services.
  • CO197—Contractual obligation pre-certification, authorization, or notification is absent.
  • CO252—Payer will reconsider the claim when additional information is received.
  • CO96—Noncovered charges.
  • CO55—Experimental or investigational test.

Among the segments tracked in the study, molecular labs had the highest denial rate at 27%, followed by anatomic pathology at 19% and clinical laboratories at 13.6%. Each of these segments has seen varying trends in the reasons for claim denials.

“For labs in the molecular space, ‘experimental and investigational with no prior authorization’ denials have become very familiar over the last several years,” Richard said. “However, in routine anatomic pathology, prior-authorization denials continue to be one of the fastest-growing denial types.”

Richard and Denham will go more in depth at EWC ’24, including offering additonal best practices.

That’s it for this week. More dispatches to come. Hope to see you and your “krewe” in New Orleans.

(Bob Croce is Executive Publisher/General Manager of The Dark Intelligence Group, the company that brings you the Executive War College. Have a question or comment for Bob, you can reach him at

Get more info now on the 2024 Executive War College

See yourself in this picture!
A scene from our EWC 2023 welcome reception.

Lean for lab leaders

Click on the video blow of EWC producer Robert L. Michel to hear more about
the Lean for Lab Leaders Workshop on Day 3 of Executive War College.

Newly added speakers and topics

(Here are some recent additions to the EWC ’24 agenda)

Speaker: Heather Agnostinelli
Executive Director of Clinical Laboratory Operations,
Wisconsin Diagnostic Laboratories
Milwaukee, WI.

Speakers:Heather Agnostinelli
Vice President, Head of Specialty RCM and Clarisa Blattner, Senior Director of Revenue and
Payer Optimizations,
XIFIN, San Diego, CA.

Speaker:Laura Tafe, MD, Associate Professor of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH.

Speakers: Diana Richard, Senior Director, Pathology and Strategic Development and Stephanie Denham, Associated VP of RCM and Analytics, XIFIN, San Diego, CA.

Speaker: Paul Chenery
Head of Quality, Training & Strategic Improvement,
Nottingham University Hospitals NHS Trust,
Nottingham, England, UK

For ongoing updates, check out our agenda page.

Hear below what attendees had to say about EWC in 2023