Q&A: Analyzing skin substitute claims

Q: How can revenue integrity teams validate reimbursement performance for skin substitute products?

A: Organizations should not assume that reimbursement remained revenue neutral simply because claims are processing successfully. Many commercial payer contracts, fee schedules, and reimbursement methodologies are tied to legacy Healthcare Common Procedure Coding System (HCPCS) structures. As a result, some organizations may now be experiencing reimbursement degradation that is not immediately obvious through standard claim edit monitoring alone.

Revenue integrity teams should be evaluating:

• Payment variances by payer, including variances from expected and actual payments
• Changes in denial trends by payer, with particular focus on prior authorization or medical necessity denials
• Need to update/amend contractual agreements and/or rate sheets with payers
• Increased write-offs or payment delays

Commercial payer behavior related to CMS changes is typically difficult to predict, which is why early claims-based analysis is necessary. Although CMS has established the new reimbursement framework, some managed care organizations may still be operationalizing changes internally or applying legacy reimbursement logic inconsistently. Remember, under HIPAA code set requirements, both providers and payers are expected to adopt and be up to date with HCPCS Level I and Level II coding changes. Revenue integrity professionals should carefully compare reimbursement patterns before and after implementation to identify potential revenue leakage.

Editor’s note: This answer was excerpted from “Evaluating the impact of skin substitute payment reform in 2026: What revenue integrity teams should consider,” in the July 2026 issue of the NAHRI Journal. The NAHRI Journal is a quarterly journal featuring in-depth analysis and expert advice and is an exclusive benefit of NAHRI membership. Not a member? Join today.