March 25, 2021
By Andrew D. Markiewitz, MD, MBA-Healthcare
An Approach to Appealing DRG Denials
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…
March 18, 2021
By Andrew Wachler, Esq. and Kaitlin Nucci, Esq.
A Novel Approach to Defending Technical Denials
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’…
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…
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Editorial Board
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Adam J. KleinAllen Jost, PhDAlvin Gore, MD, CHCQM and Cathi Charlberg, LVN, CHCQMAmanda Gilliland, RN, BSNAmber Soucy, MSN, RNAndrew B. Wachler, Esq.Andrew B. Wachler, Esq. and Emma E. TrivaxAndrew H. Hughes, MD and Charles Locke, MD, CHCQM-PHYADVAndrew Wachler, Esq. and Kaitlin Nucci, Esq.Andrew Wachler, Esq., and Sarah Hillegonds, Esq.Angela Phillips, PTAspen AlbrightBarbara Vandegrift, RN, BSN, MABecky Rodrian, CPC, CEMC, CBCS, MBSBenjamin Kartchner MD, CHCQM-PhyAdvBrian T. LandryChristina Panos, RHIA, CTRChristopher Halleman, DOChristopher J. Laney, Esq.Chuck BuckClark AnthonyColleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RNDaniel Zirkman, MDDavid A. McKenzie, CAEDavid Jury MD, MSDavid M. Glaser, Esq.Delilah Davis, RN, BSN, CCADenise Coleman, LPNDenise Nash, MD, CCS, CIMDheeraj Mahajan, MD, FACPDuane Abbey, PhD, CFPEdward Hu, MD and Charles Locke, MDEdward Roche, PhD, JDElizabeth C. Dunbar, MD, MBA, FACEP, CHCQM-PHYADVEllen Fink-Samnick MSW, ACSW, LCSW, CCM, CRPEllen Parucka Walker LCSW ACSWErica E. Remer, MD, CCDSErin Diesel Roumayah, Esq.Frank D. Cohen, MPA, MBBGlenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAMGloryanne Bryant, RHIA, RHIT, CCS, CCDSGreg FordHolly Louie, RN, BSN, CHBMEJ. Paul Spencer, CPC, COCJanelle Ali-Dinar, PhDJeffrey D. Lehrman DPM, FASPS, MAPWCAJessica Forster, Esq.John Foggle, MDJohn K. Hall, MD, JD, MBA, FCLM, FRCPCJulia K. Brodt, PhDJuliet B. Ugarte Hopkins, MD, CHCQM-PHYADVKaitlin Nucci Esq.Kathleen K. Borchard, BSN, RN-ACMKathy Seward, MD, CHCQM-PHYADVKim T. Charland, BA, RHIT, CCSKnicole C. Emanuel Esq.Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainerLaurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS TrainerLeslie Marsh, RN, BS, MSN, MBALori O’Hara, MA, CCC-SLPMadison AllenMaggie Elehwany, JDMark SpiveyMarvin D Mitchell, RN, BSN, MBAMary Beth Pace, RN, BSN, MBA, ACM, CMACMary Inman, Esq. and Anne Hayes Hartman, Esq.Mary Inman, Esq. and Max Voldman, Esq.Matt Lambert, MDMatthew AlbrightMaureen Testoni Esq,Max Voldman, Esq.Melinda Battaile, MD, FHM, MMCI, CHCQM-PHYADV, CCDSMichael A. Salvatore, MD, FACPMichael KennedyMichael Rosen, Esq.Nancy J. Beckley, MB, MBA, CHCNena Scott, MSEd, RHIA, CCS, CCS-P, CCDSPhillip Angello, MDRalph Wuebker, MD, MBARichard “Dick” Beckley, YNS, USN, 1966-1970Robin Sewell, CDIP, CCS, CPC, CICRonald Hirsch, MDSarah Hillegonds, Esq.Sean M. Weiss, CEMA, CMCO, CPMA, CPC-P, CMPE, CMPM, CPC-PSean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC and David Glaser, Esq.Shannon Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA®Stanley Nachimson, MSStefani Daniels, MSN, RN, CMAC, ACM and Tiffany Ferguson, LMSW, ACMStefani Daniels, MSNA, ACM, CMAC
