If you’re in pathology, you’ve probably heard it before:

“That service isn’t covered.”

“Modifier not valid.”

“Included in hospital payment.”

But here’s the truth: most of those denials? They’re not just frustrating—they’re beatable. And ignoring them could be the biggest reason you’re not collecting everything you’ve earned.

Let’s break down why clinical pathology denials happen—and what to do about them.

Why Clinical Pathology Denials Are So Common

Managed care companies have one goal: save money.

One of their favorite tactics? Denying claims for the professional component (PC) of clinical pathology.

Their excuses vary:

  • Modifier 26 is “invalid”
  • The service is “included in the hospital payment”
  • The claim is missing medical necessity documentation
  • “This isn’t a covered benefit” (even though it is)

David Smith, pathology billing expert at MedReceivables Advisor, an Infinx company, has spent decades battling these denials. His experience shows that many of these payer tactics are designed to wear you down—not because they’re accurate.

The Danger of Ignoring Denials

Too many billing companies write off small-dollar denials. But that’s a mistake.

If you don’t appeal, you can’t litigate. ****And litigation is often the only way to get certain payers to reimburse for clinical pathology services.

Here’s what David’s team does differently:

  • Appeals every denied claim—even the $5 ones
  • Customizes denial language per payer
  • Tracks denial trends by state and contract status
  • Brings in legal support on contingency (no cost to the client)

The result? Denials become opportunities—not dead ends.

How to Build a Better Denial Strategy

Winning back clinical pathology payments requires a smarter, more aggressive approach. Here’s how to start:

  • Track denials by payer and reason code. Don’t lump all rejections together. What works for Cigna won’t work for Aetna.
  • Ensure your documentation supports your codes. For stains, panels, and multi-site biopsies, your reports must clearly support the units and modifiers you’re billing.
  • Standardize appeals—but customize your language. Use payer-specific wording that’s been tested and reviewed by legal experts.
  • Include backup data. Especially for molecular or high-volume lab testing, include medical necessity information upfront.
  • Appeal everything. Every claim matters—not just for revenue, but for future legal recourse.

Don’t Let Payers Decide What You Deserve

Payers often claim they “follow Medicare rules”, but in most states, they’re not reimbursing hospitals for the professional component (PC) of clinical pathology—and they know it. Meanwhile, hospitals typically aren’t billing for the PC either. That leaves your pathology group as the only one in position to go after this revenue.

And yes, it can take dozens of appeals, months of tracking, and legal escalation to get what’s rightfully owed. But if the claim is valid, you deserve to be paid.

Final Takeaway

Clinical pathology denials aren’t the end of the story—they’re just the beginning of your strategy.

If your current billing partner isn’t appealing every claim or isn’t equipped to fight back with the right tools and legal resources, you’re leaving revenue behind. Stop accepting the “no.” Start getting paid.

For more on this topic, watch David Smith’s webinar on-demand or request a demo here.