The Ultimate Playbook for Mastering Claims Denials and Winning Appeals
The best strategy is to prevent denials before they occur. This requires having enough resources, a well-thought-out plan, educated stakeholders, and regular compliance audits. If budget constraints are a concern, calculating revenue loss from denials can help make the case for additional staff. To take immediate action, consider partnering with a vendor specializing in denials management and prevention. They can perform targeted audits, use advanced analytics to analyze audit data, and prepare a plan to prevent denials. This investment is likely to yield significant returns.
REFLECTIONS
• Is your organization’s audit plan specifically designed to prevent denials, not just manage them? • Does your audit plan include all key departments, such as Case Management, CDI, and HIM/Coding? • Is your audit plan customized to your organization’s specific denial trends and challenges? • Is your audit plan updated regularly to align with trends, regulatory changes & industry alerts? • Do all stakeholders have visibility into your audit results? • Do all stakeholders receive education on regulatory changes, OIG workplan changes, denials trends, and appeals outcomes? • Do you conduct follow-up audits after educating stakeholders to ensure they have understood and implemented new information?
AUDIT TARGETS
An organization should base its prevention audits on observed denial trends and known at-risk areas, such as:
• • • • • • • • • •
Medical necessity Clinical validation
Documentation integrity High-dollar procedures Error-prone DRGs and APCs
Error-prone diagnoses & procedures
HCCs
Diagnoses at-risk for miscoding
OIG Workplan targets
Recovery Audit Contractor (RAC) targets
• The Program for Evaluating Payment Patterns Electronic Report (PEPPER) data • NCCI edits • Modifier accuracy
It is best to convey the audit findings as educational opportunities that highlight the knowledge gaps identified in critical areas such as Case Management, HIM, and CDI. Sharing the results with all relevant stakeholders ensures that everyone is well-informed and can take necessary actions.
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