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Providers must learn to pick their battles in pushing back against questionable recoveries. Denials pit insurers against hospitals. Despite costly attention, improved clinical documentation remains elusive. Insurers retain premium dollars for their stockholders – not their customers, our patients. They save by downgrading severe diagnoses (MCCs) or removing moderate co-morbidities…
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Providers should be aware of these emerging strategies for defending against audits. For years, providers have been plagued with defending claims for medically necessary services that have been denied due to insufficient documentation and technical reasons. This leads to the Medicare program and commercial payers unduly benefitting, as the programs’…
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Your data will determine the overall success of your denial prevention and management efforts. No matter how robust the clinical documentation integrity (CDI) program, there are still payer denials. Payer audits become more creative and voluminous each day. Just when we think we have a handle on the top clinical…
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Hospitals may consider abandoning their contracts. There are few things managed Medicare plans have come up with that are more unfair to hospitals than denials due to readmission. Hospitals with contracts with managed Medicare payers often must endure these denials, as they are not often excluded in contracts. Managed Medicare…
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“Urgent” memo marks obvious disagreement among contractors. In what can only be described as highly unusual, a Medicare Administrative Contractor (MAC) has advised home health providers who have had claims audited and denied by the Comprehensive Error Rate Testing (CERT) contractor to appeal those denials. The announcement was made today…
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Not all P2Ps should be pursued. In my reporting a few weeks ago, I encouraged physician advisors and other leaders in case management to analyze the outcomes of their peer-to-peers (P2Ps). As a reminder, P2P conversations revolve around the appropriateness of Inpatient status and take place between the medical director…
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CERT claim review highlights need for strategic approach. How do you handle your appeals when there is more than one issue being denied? For example, if the payer denies both the medical necessity of the level of care as well as the coding of a procedure, what strategies should you…