Determining which denials could be overturned on appeal is key to a successful denial management program. Learn how to leverage your appeal team's knowledge to create a data-driven scoring system.
Q: As utilization review case managers, we are often tasked with assessing our hospital's risk for novel coronavirus (COVID-19) denials. What are the most important measures we should be examining?
Judith L. Kares, JD, writes about the unique coverage, billing, and payment rules that apply to these blood products and related services under Part B.
The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a rich source of data. Consider how to use the PEPPER to guide coding and CDI process improvements.
Clinical validation reviews and queries ensure that the documented diagnoses and clinical indicators hold up to inspection. Use these strategies to head off clinical validation reviews and improve documentation.
Q: How should we handle denied claims when the payer refuses payment under the billed status? Do we need to document that the status was changed only because the payer did not agree to any other options?
As Medicare Advantage makes strides to becoming the new norm, organizations need to establish new processes, educate staff, and advocate for patients. Learn how your organization can keep pace with change before it’s too late to catch up.
