November 5, 2019
Government and Private Insurer DRG Audits – Don’t (Necessarily) Believe the Denial!
EDITOR’S NOTE: This is the second portion of a two-part series of articles highlighting detailed examples of two challenged denials that followed third-party healthcare audits. In our second example, a 73-year-old female presented to the hospital with syncope following a fall at a physician office: The provider assigned I67.1 (Cerebral…
October 11, 2019
Government and Private Insurer DRG Audits – Don’t (Necessarily) Believe the Denial!
EDITOR’S NOTE: This is the first in a two-part series of articles highlighting detailed examples of two challenged denials that followed third-party healthcare audits. I shouldn’t be surprised. I have been reviewing denials by insurance companies since the late 1980s. I’ve seen the same things over and over again, such…
January 29, 2019
Appealing Clinical Validation Denials in the Era of Sepsis-3
Higher overturn rates noted when the appeal is filed outside of the payer’s internal appeal process. I’d like to share some information gained from appealing over 2,000 clinical validation denials for sepsis in the state of New York since the time of the release of the Sepsis-3 criteria in February…
January 15, 2019
Appealing Clinical Validation Denials is a Team Effort
Clinical validation denials continue to climb. When payers issue clinical validation denials, they challenge diagnoses documented in the chart by the providers caring for the patient. Sometimes, it’s not simply the validity of diagnoses in question, but whether coding rules were violated. This being the case, assessment and subsequent potential…
July 17, 2018
Is All Airway Protection Acute Respiratory Failure?
Document it right on the front end; avoid fighting a denial on the back end I was recently asked about a post from Hospital Performance regarding acute respiratory failure and airway protection (https://soundphysicians.com/blog/2018/06/20/from-the-appeals-desk-acute-respiratory-failure-part-1-2/), and I wanted to expand on what the author, Dr. Hesham Hassaballa, wrote. A key point is…
January 15, 2018
CDI and Medical Necessity: Closing the Gap Could Prevent Denials
Medical policies are based off of evidence-based medicine. Without proper documentation, however, most providers struggle to get services or procedures covered for patients.Exactly what is medical necessity? To many, it is the belief that a service or procedure is warranted or justified for a patient. Others view it as a…
June 12, 2017
Learning How to Avoid Sepsis Denials
In short, you can avoid sepsis denials when documentation in the patient encounter shows a clear delineation of a non-systemic infection. This is the only ironclad defense that will withstand any and all scrutiny. Sepsis clinical parameters are good for capturing and preempting even early sepsis cases, but unless the…
May 22, 2017
Moving from Denial Management to Prevention
An estimated 20 percent of all healthcare claims in the U.S. are denied each year. The financial impact for some hospitals is estimated to be in the range of $250 million annually.When denials are appealed, success rates can vary from 55 to 98 percent.Some hospitals are moving from denial management…
Much attention and dedicated work have been devoted toward clinical documentation improvement and accurate, specific coding. Clearly, those are of great importance. However, I want to address the physician Part B insurance denials that have nothing to do with how good the clinical documentation is and how accurate the coding…
May 8, 2017
Rising Claim Denials under ICD-10
Now that ICD-10 has been with us a while, the most frustrating tasks that hospitals are dealing with are claims denials. Whether for line items or entire stays, they present significant challenges as it pertains to revenue and resources. Does your facility have the proper process in place to handle…