Denials and appeals

Q: Are there any best practices for managing additional documentation requests (ADR)?

Q: What is a denial avoidance program and how does it differ from a denials management program?

What strategies should hospitals follow for deciding whether to appeal denied claims and submitting appeal letters?

Many HIM directors find that managing the coding team requires a different type of focus than other functions within the department. This may be true because coding professionals have advanced education, prefer a quiet work environment, and require less direction.

What is a good strategy for sharing denials data with the medical staff to ensure they understand weaknesses?

The Office of Inspector General (OIG) plans to address concerns regarding capitated payment models by putting preauthorization denials under review.

When evaluating a code edit, it’s necessary to understand exactly when or where in the claim or billing process the edit arose. Look to coding guidance to help edit resolution efforts.

What strategies would you recommend for building an effective denials management team?

CMS instructed Medicare Administrative Contractors (MAC) to review previously denied 2018 outpatient therapy claims reported with modifier -KX. However, because MACs might not automatically review all denied therapy claims, providers will need to initiate the process.

Incorrect inpatient rehabilitation facility (IRF) claims led to $444,458 in overpayments at Memorial University Medical Center, a Savannah, Georgia-based hospital, according to a recent Office of Inspector General audit report. IRF billing compliance has been on the OIG’s radar for several years, and Medicare Administrative Contractors and supplemental medical review contractors have been placing these claims under increased scrutiny.