The Ultimate Playbook for Mastering Claims Denials and Winning Appeals
Utilizing software to log denials and track appeal deadlines, accessible to all stakeholders, is a relatively simple solution for delayed appeals. Should a backlog exist, an organization can either require staff to work overtime to meet the demand or seek the help of an external entity that has a track record of success. It’s crucial for organizations to have a zero-tolerance policy toward preventable revenue loss and allocate whatever resources are needed to prevent it.
Solutions by Job Function
In the following section, we will explore how Case Management, CDI, and HIM can provide effective solutions for various types of denials.
Case Management
• Case Managers have a unique role in helping prevent Prior Authorization Denials. As the
• When it comes to Medical Necessity Denials , Case Managers play an important role in prevention by performing timely, accurate, and thorough continued stay reviews, providing the correct information to payors, and being proactive in preparing for upcoming reviews. On the individual level, the medical necessity process begins at admission and then at regular intervals with continued stay reviews. The frequency of the continued stay review is determined by hospital policy, with varying cadences for different payors. For example, a hospital may require daily reviews for Medicare patients, but commercial payor reviews may be required every other day. The continued stay review provides the documentation that the patient still meets inpatient hospital level of care.
primary point of contact with insurance companies after patients are admitted and initial reviews are conducted, they are among the first to know about breakdowns in the admission authorization process. First, a denial will occur if no prior authorization was obtained. Second, even if prior authorization was obtained, it may result in non-payment if the admission authorization was submitted to the payor after the deadline. Case Managers can work with the department responsible for obtaining admission authorizations to help streamline the process and prevent future prior authorization denials from occurring.
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