New Year’s Resolution: Decreasing Denials with Proactive Tactics

The cost to appeal is worth the claim reimbursement and modification of payer behavior.

As we approach 2022, one of our new year’s resolutions should be to do what’s necessary to decrease denials. We know that payers and external auditors took a break during the pandemic, but now it’s open season for audits and denials.

Let’s consider some focused strategies to limit our denial exposure in 2022.

Know What’s Being Targeted

Obtain data from patient financial services (PFS). PFS should be able to tell you what the top 10 denial categories are for your organization. Watch your Program for Evaluating Payment Patterns Electronic Reports (PEPPER) for indications of variant patterns of your facility versus other organizations. Also, visit your Recovery Audit Contractor’s (RAC’s) and other RACs’ websites to understand what they are targeting. For professional practices, look at any Comprehensive Error Rate Testing (CERT) reports. Then convene a task force that includes health information management (HIM), coding, PFS, and other relevant departments to identify potential process modifications or education opportunities to reduce denials.

Common targets include the following:

  • Diagnosis specificity: Be certain that your clinical documentation improvement specialists (CDISs) know the targets and channel their initiatives and physician education on these conditions;
  • Lack of clinical indications for certain conditions: Understand each payor’s rules, know which model (i.e., Milliman or InterQual) they use, and discuss the requirements and fiscal impacts with your physician advisors and medical staff leadership and related clinical departments (i.e., imaging, nutrition); also, provide education at any physician forums available; and
  • Medical necessity: Ensure that your case management team, CDISs, and clinical leadership are fully aware of payor and RAC targets, and ensure that the clinical documentation supports the service, level of care, and place of care.

Payer Denials

When we receive a payor’s denial we don’t agree with, we need to aggressively and logically appeal – every time! Remember, payors are incentivized to deny claims that delay or eliminate payments. You must know your payor contracts. You need to be persistent and argue by providing compelling reasons supported by your patient records. If need be, pursue every level of appeal available to you. We need to establish a reputation with the payor of not laying down and letting them walk all over us.

Determine if you have grounds for an appeal by first researching the payor’s rationale for the denial. If the payor erroneously misinterpreted the clinical process, contract, or rules related to the service, prepare a compelling defense by:

  1. Providing concrete proof that you are entitled to the payment;
  2. Using the opportunity to present information that was incorrectly interpreted or wasn’t considered by the payor’s initial reviewer; and
  3. Ensuring that the appeal is based on a payor’s misinterpretation, not your error.

Your appeal should clearly state what was done for the patient and how your organization complied with your organization’s contract with the payor and the payor policies, such as obtaining a pre-authorization, notifying the payor within the timeframe required, providing copies of records with the claim, coordinating with their case management personnel, etc.  Follow the IRAC process:

IRAC (Smartt 2020) — Issue, Rule, Analysis, and Conclusion

  • Issue – Clearly Identify the reason for the denial and address it;
  • Rule – Lay out the rule(s), statute, or policy that apply to the denial and demonstrate what you did for the patient or why the payor can’t enforce their denial; be certain to know your state statutes relative to payor behavior;
  • Analysis – Give a detailed analysis that demonstrates how what was done for the patient followed the payor’s procedures, patient care protocols, community practices, and national/specialty standards; provide excerpts of the medical records that support what was done; and
  • Conclusion – Demand the payor review and overturn their denial.

Documentation Submitted

Many organizations have delegated documentation submission to PFS. Reconsider this delegation. Collaborate with PFS to delineate when documentation may be submitted by PFS staff versus when the submission should be by the denials management or coding appeals team.

Any documentation provided should have valid signatures, dates, and plans of care consistent with the services provided. This is particularly important when providing documentation for physician/professional service claims and denials.

When It’s Time to Call in the Troops

If your organization is doing what’s needed to ensure that your documentation supports the care provided and your payors or external auditors continue to deny for what seems to be excessive frequency, inappropriate reasons, or as a tactic to exhaust facilities or providers, you may need to pull in legal counsel. Be certain that the counsel has payer experience.

Ensure that you have collected data from your return to provider (RTP) documents, 835s, and 837s, which demonstrate that the payor is intentionally denying for invalid reasons or in contradiction of your contract. These trends will help your legal counsel build the complaint. If needed, complain to your state department of insurance and/or pursue a declaration of breach of contract for timely payment and/or payment of medically necessary services.

It’s time to be focused and aggressive. The cost to appeal is worth the claim reimbursement and modification of payer behavior. Be certain to monitor your progress and denial activity for positive results, and celebrate!

EDITOR’S NOTE: For more on this topic, please see other articles written by Rose Dunn and which have been posted on ICD10monitor.

Facebook
Twitter
LinkedIn

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Comprehensive Outpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

September 5, 2024
Advanced Outpatient Clinical Documentation Integrity: Mastering Complex Narratives and Compliance

Advanced Outpatient Clinical Documentation Integrity: Mastering Complex Narratives and Compliance

Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.

September 12, 2024

Foundations of Outpatient Clinical Documentation Integrity: Best Practices for Accurate Coding and Compliance

This webcast, presented by Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, a recognized expert with over 30 years of experience, offers essential strategies to improve outpatient clinical documentation integrity. You will learn how to enhance the accuracy and completeness of patient records by adopting best practices in coding and incorporating Social Determinants of Health (SDOH). The session also highlights the role of technology, such as EHRs and CDI software, in improving documentation quality. By attending, you will gain practical insights into ensuring precise and compliant documentation, supporting patient care, and optimizing reimbursement. This webcast is crucial for those looking to address documentation gaps and elevate their coding practices.

September 5, 2024
Preventing Sepsis Denials: From Recognition to Clinical Validation

Preventing Sepsis Denials: From Recognition to Clinical Validation

ICD10monitor has teamed up with renowned CDI expert Dr. Erica Remer to bring you an exclusive webcast on how to recognize sepsis, how to get providers to give documentation that will support sepsis, and how to educate to avert sepsis denials. Register now and become a crucial piece of the solution to standardizing sepsis clinical practice, documentation, and coding at your facility.

August 22, 2024

Trending News

Featured Webcasts

Post Operative Pain Blocks: Guidelines, Documentation, and Billing to Protect Your Facility

Post Operative Pain Blocks: Guidelines, Documentation, and Billing to Protect Your Facility

Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.

October 24, 2024
The OIG Update: Targets and Tools to Stay in Compliance

The OIG Update: Targets and Tools to Stay in Compliance

During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.

September 19, 2024
Pediatric SDoH: An Essential Guide to Accurate Coding and Reporting

Pediatric SDoH: An Essential Guide to Accurate Coding and Reporting

This webcast, presented by Tiffany Ferguson, LMSW, CMAC, ACM, addresses the critical gap in Social Determinants of Health (SDoH) reporting for pediatric populations. While SDoH efforts often focus on adults, this session emphasizes the unique needs of children. Attendees will gain insights into the current state of SDoH, new pediatric Z-codes, and the importance of interdisciplinary collaboration. By understanding and applying pediatric-specific SDoH factors, healthcare professionals can improve data capture, compliance, and care outcomes. This webcast is essential for those looking to enhance their approach to pediatric SDoH reporting and coding.

August 8, 2024
Oncology and E/M Services: Compliance, Medical Necessity, and Reimbursement

Oncology and E/M Services: Compliance, Medical Necessity, and Reimbursement

Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, VP of CDM, for a webcast addressing oncology service coding challenges. Learn to navigate coding for infusions and injections alongside Evaluation and Management (E/M) services, ensuring compliance and accurate reimbursement. Gain insights into documenting E/M services for oncology patients and determining medical necessity. This webcast is essential to optimize coding practices, maintain compliance, and maximize revenue in oncology care.

July 30, 2024

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

👻Spooky Sale is Back!👻 Get 31% off all three Medlearn brands, using code SPOOKY24.