September 24, 2020
By Robin Sewell, CDIP, CCS, CPC, CIC Five Data Analytics Metrics That Help Prevent and Manage Denials
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…
By Howard Stein, DO, MHA, CHCQM-PHYSADV
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…
January 21, 2019
By Chuck Buck BREAKING: MAC Advises Providers to Appeal Denials
“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…
April 12, 2018
By Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV Are Peer-To-Peers Worth It? Physician Reaction
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…
September 28, 2017
By Denise Wilson, RN, MS, RRT One Claim with Multiple Denials Calls for Smart Defense
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…