By Tim Brundage, MD, CCDS

A recent study by Kodiak analyzed claims data from 1,900 hospitals. Significant insights emerged regarding compliance with the Medicare Two-Midnight Rule among various payers, including commercial managed care plans, Medicare Advantage (MA) plans, and traditional Medicare. The findings underscore a critical issue that hospitals face today: payers often apply their criteria for inpatient admissions rather than adhering to the Two-Midnight Rule for all Medicare beneficiaries.

The Centers for Medicare and Medicaid (CMS) mandated use of the Two-Midnight Rule when determining the medical necessity of inpatient services by MA plans effective January 1, 2024.  Although Medicare Advantage beneficiaries are entitled to the same covered services as those with traditional Medicare, they have historically experienced lower inpatient rates due to stricter medical necessity criteria. Implementation of the Two-Midnight Rule was supposed to eliminate that discrepancy.

Despite the new Medicare Advantage coverage changes, the data suggest widespread non-compliance, which poses a financial risk to hospitals.

The study reveals that Medicare Advantage plans have yet to fully comply with the Two-Midnight Rule, leading not only to revenue loss but unnecessary expenses for hospitals when appealing these noncompliant denials. This trend highlights the urgent need for hospitals to be vigilant in monitoring MA plan medical necessity denials.

At Brundage Group, we understand the complexities of navigating this landscape. Our expertise in overturning medical necessity denials is more crucial than ever in this environment of payer non-compliance. Our team challenges inappropriate denials, making sure hospitals capture appropriate revenue for the care delivered to MA plan beneficiaries in good faith.

The findings from Kodiak’s study remind Brundage Group of our critical role in safeguarding our hospitals’ interests. Our compliant approach to medical necessity denials helps to ensure admissions are accurately classified according to established guidelines.

By partnering with Brundage Group, you gain access to a team knowledgeable about the Two-Midnight Rule and adept at leveraging data-driven insights to strengthen your case against payer denials. We actively monitor trends by payer, provide expert guidance, and share valuable information to enhance your organization’s ability to navigate these challenges.

The data from Kodiak’s study highlights the pressing need for healthcare systems to be proactive with their utilization review strategies. With Brundage Group, you will be prepared to challenge unjust denials and benefit from our extensive knowledge of payer behaviors and regulatory requirements.

In an increasingly complex compliance landscape, Brundage Group’s expertise in overturning medical necessity denials is a key resource for healthcare systems. Our expertise, combined with insights from proprietary analytics platform, equips hospitals to navigate the nuances of payer behaviors confidently.

In today’s healthcare landscape, where operating margins are tightening and administrative burdens are increasing, hospitals face the critical challenge of ensuring they capture every dollar of earned revenue. While front-end revenue cycle activities like patient registration and back-end activities like billing and collections are often well-monitored, the mid-revenue cycle—a crucial phase that includes utilization management, clinical documentation integrity (CDI), and denials management—is frequently overlooked.

Optimizing the mid-revenue cycle is essential for preventing revenue leakage and maximizing reimbursement. At Brundage Group, we understand the complexities of this critical stage and offer specialized services to help hospitals streamline their processes and capture the revenue they deserve.

The mid-revenue cycle is the keystone connecting clinical care delivery with the financial processes that follow. It involves ensuring that patient care is accurately documented, appropriately coded, and compliant with payer regulations while managing the utilization of hospital resources. This stage directly impacts the accuracy of billing, the effectiveness of denial management, and, ultimately, the hospital’s financial health. 

However, mid-revenue cycle departments often operate in silos, leading to inefficiencies and missed opportunities for accurate claim submission. For hospitals to optimize this phase, collaboration across departments is crucial. This is where Brundage Group’s Physician Advisors play a pivotal role.

Hospitals need a dedicated Physician Advisor for each core area of responsibility: utilization management, clinical documentation integrity, and denials management to effectively bridge the gaps between the various mid-revenue cycle departments. These Physician Advisors act as “quarterbacks,” promoting collaboration across departments that are often working in isolation.

A dedicated Physician Advisor in utilization management ensures that patient status is correctly assigned, resources are used efficiently, and care is delivered in compliance with payer requirements. This prevents costly denials and ensures that hospitals are reimbursed appropriately for the care provided.

Accurate and comprehensive clinical documentation is the foundation of proper coding and billing. A Physician Advisor focused on CDI and coding works closely with physicians, CDI, and coding staff to ensure that the documentation reflects the complexity of care delivered. This supports accurate reimbursement and mitigates the risk of audits and penalties.

Denials are a significant source of revenue leakage for hospitals. A Physician Advisor dedicated to denials management can proactively identify trends, address root causes, support creation of appeal letters, and lead peer-to-peer discussions with payers to overturn denials. This reduces the burden on clinical staff while improving hospital finances

At Brundage Group, our team of seasoned Physician Advisors brings a wealth of expertise in mid-revenue cycle optimization. Our holistic approach focuses on utilization management, CDI, and denials management to ensure that hospitals capture every dollar of earned revenue.

In a time when every dollar counts, optimizing the mid-revenue cycle is essential for hospitals to remain financially viable. Hospitals can significantly reduce revenue leakage and maximize reimbursement retention by ensuring collaboration across utilization management, clinical documentation integrity, and denials management.  

Brundage Group’s dedicated Physician Advisors are the key to unlocking this potential, serving as the “quarterbacks” who drive collaboration and efficiency across the mid-revenue cycle. With our support, hospitals can capture their earned revenue and strengthen their financial health in a challenging healthcare environment.

Accurate hospital claims are crucial. It ensures seamless insurance reimbursements, promoting financial health within hospitals. Moreover, Clinical Documentation Integrity (CDI) plays a pivotal role in maintaining this accuracy, as CDI specialists undergo rigorous education to validate and enhance clinical documentation excellence.

In the precision-driven world of healthcare, CDI stands as a pillar. The process involves thoroughly scrutinizing medical record documentation to ensure completeness and accuracy. Think of CDI specialists as gatekeepers who monitor data correctness within hospital systems; they hold pivotal roles in preserving system-wide harmony. Adherence to strong CDI practices can improve coding accuracy, mitigate compliance issues, and reduce future denials.

Crucial to the claims process, accurate hospital medical coding ensures hospitals receive their due compensation. When healthcare professionals provide services within the hospital setting, appropriate ICD-10 codes that are primarily assigned based on provider documentation must correlate with patient conditions and procedures performed. As providers feel more and more rushed when documenting patient encounters, they may omit significant details that impact accurate code assignment.

Coding is a very exact discipline that is based on a dictionary. If appropriate terminology that corresponds to a diagnosis code is not documented, that condition will not be accurately represented on the hospital claim. Coders can only assign code based on what is explicitly documented. They cannot make inferences. CDI professionals help bridge this communication gap.

Additionally, coder performance is measured through productivity and how many records they can code each day. Pressure to reach a particular volume of completed records can lead to missed opportunities. When coders do identify opportunities, it is often difficult to obtain provider cooperation because coding is a post-discharge activity, so the provider may not recall the issue in question. CDI professionals review the health record concurrently while the patient is in the hospital. Therefore, identified opportunities can be reconciled while the provider is still caring for the patient, which improves their level of cooperation.

Notably, it contributes to data analysis for improved health policies and outcomes. However, simple human error can lead to mistakes that significantly impact claim results through rejections or audits, leading to penalties, decreased revenue, and potentially damaging reputations. Robust quality assurance programs should be instituted to monitor outcome performance. Automation tools should be employed, where possible, to minimize risks and enhance accuracy. Clear communication should be fostered amongst all stakeholders, including doctors and other relevant personnel involved throughout documentation until the final coding stages.

The CDI specialist plays a pivotal role in improving financial outcomes for healthcare organizations. Their work involves enhancing the accuracy and specificity of clinical documentation, which directly influences hospital coding and billing processes. When document details are crystal clear and in a language that corresponds to coding lexicons, the complexity of patient conditions is accurately represented, resulting in appropriate reimbursement rather than an underpayment due to ambiguous or insufficient information.

Moreover, their keen eye may uncover overlooked opportunities and instances where rightful reimbursement was missed initially but is rightfully deserved after review. Comprehensive notes lessen the risk of claim denials while ensuring smoother revenue cycle management operations, helping drive fiscal health within hospitals.

Appropriate reimbursement hinges on the precision of hospital medical coding. When hospitals use correct codes, they outline an accurate picture of a patient’s clinical scenario. These snapshots are critical for insurance companies to decipher patient acuity as well as what services have been provided. Errors in this process can cause significant disruptions to hospital cash flow. Moreover, coding based on inaccurate documentation could lead to claims denial from insurance companies.

This implies that hospitals might not receive any compensation for the high-quality services they render, a situation both unfavorable and avoidable through precise documentation that supports code assignment. Thus, maintaining accuracy throughout the entire documentation process is something hospitals should make sure happens consistently within your facility. It assures timely payment without interruptions impacting revenue stream stability.

Inaccuracies in hospital coding can lead to severe consequences. If errors creep into the system, these mistakes could jeopardize your healthcare organization’s financial well-being. One must maintain vigilance at every stage while dealing with the intricate details involved in accurate hospital coding and claims submission.

Coding accuracy in hospital claims streamlines the medical billing process. This crucial step prevents unnecessary delays or denials, promoting efficient revenue cycle management for healthcare institutions. Therefore, Brundage Group’s commitment to precision cannot be understated; it compliantly optimizes financial outcomes and reduces payer denials.

In healthcare, claim denials represent a formidable challenge for hospitals. The impact of claim denials is significant, affecting the financial stability and operations of these institutions. Mastering this aspect ensures smooth cash flow, fosters patient satisfaction, and maintains business health and viability.

Let’s delve into how hospitals can avoid the five frequent mistakes leading to claim denials.

Accurate coding plays a significant role in avoiding claim denials. As you navigate the labyrinth of medical billing, recall that payers meticulously scrutinize every detail on your claims submission; an overlooked modifier or prior authorization will not escape their notice. This underscores the need for proper and complete filling out of all necessary fields within claim forms by your team members handling this task.

Make it second nature to them: check those commonly skipped areas like patient subscriber numbers. Correct any errors they spot before sending off these crucial documents. Keeping track of each payer’s receipt ensures no deadlines slip past unnoticed, which could lead to frustrating timely filing denials.

Establish open lines of communication between coders and billers so nothing gets missed. Accidentally truncated codes can be flagged early enough to avoid denials later down the line.

In essence, meticulousness and precision are key to maintaining high standards; even more stringent insurers won’t fault complaints resulting in denied claims.

Now, let’s talk about one crucial step: double-checking patient insurance eligibility verification. When entering data like birth dates or subscriber numbers, ensure correctness to prevent delays in claims. Make it a habit to confirm active coverage before providing treatments.

Often, with non-emergency services such as radiology procedures, you need prior authorization from insurers, so always get the green light first! Be aware of commonly excluded coverages in many health insurance plans, too. When dealing with complex healthcare plans demanding medical records for claim justification, don’t hesitate to share those details promptly!

Avoid misinformation issues prevalent today by keeping payers informed of every bit related to additional primary insurances and paid co-payments through an Explanation of Benefits (EOB). Lastly, be meticulous when encoding billing codes because simple errors can lead straight down the denial lane!

Focus on addressing upfront payment discrepancies. Always remember to review your claims carefully before submitting them. Untidy or unreadable paper forms can cause issues with payers who scan documents into their systems upon receipt.

Make sure the printer aligns well with your claim form, and always check readability. Moreover, be vigilant about including all necessary information in a claim submission. Any omissions might lead to an insurance denial due to incomplete data entry points that require filling out, such as patient subscriber numbers among others.

Don’t overlook truncated codes, either! Sometimes, diagnosis codes aren’t complete; they’re missing digits, which could result in the rejection of these entries by some insurers’ stringent standards. Regular engagement between billers and coders will allow both parties to learn from each other’s areas of expertise!

Lastly, don’t let deadlines slip away unnoticed. Timely filing prevents unnecessary rejections from the insurer’s end just because you missed their schedule window.

Certain claim errors can wreak havoc on your billing process, causing significant delays in reimbursement and failing to maintain legible claims. While the digital world dominates today’s business sphere, some insurance providers still require old-fashioned paper submissions.

Misaligned printers might distort these forms and lead to denials when insurers struggle with deciphering them. Furthermore, avoid truncated codes by expanding diagnosis documentation up to its maximum level of detail. An extra digit could make all the difference between approval or denial!

Equip your team members handling this task with coding knowledge so they can spot possible error triggers sooner rather than later. Missing information is another potential pitfall that may yield undesired results. Seemingly insignificant omissions can catch keen-eyed payers who won’t hesitate to deny incomplete applications.

Conformity stands as a vital principle: Understand individual requirements set by different insurance companies you work with regularly for ease in adherence, hence facilitating smoother transactions ahead. Lastly, don’t fall victim to tardiness. Every payer sets their unique filing deadlines, which should be honored consistently, thus saving time dealing with related complications due to late filings.

Stay vigilant about shifts in policies and regulations to sidestep cash flow roadblocks from claim denials. Payers often modify their filing schedules, leaving you prone to miss a deadline if you are not watchful.

Make use of tracking tools for each payer’s submission receipts whenever feasible. Often, unfair timely filing denials occur, even when you’ve met deadlines, but insurers deny receipt before theirs lapses. Don’t let them off!

Hold them responsible for on-schedule acknowledgments. Coded diagnoses need supreme specificity: omit a digit on that seven-digit code and expect denial as your reward! Promote open discussion among billers and codifiers, ensuring they identify truncated codes early enough, averting claim disapprovals because no diagnosis is too detailed!

Navigating handwritten claims can be dicey, with some payers sticking fiercely by paper submissions despite digital ones becoming commonplace today. Messy printouts risk rejection simply due to illegibility issues, so ensure meticulous confirmation takes place prior to dispatching any request for reimbursement against treatments offered.

Data analysis and coding accuracy checks can make navigating the pitfalls of claims denials becomes easier. Diligence in documentation management ensures correct patient information.

By having an eye for detail on procedure codes, you can avoid mismatched service claims, too. Consider embracing technology to streamline your process, offer real-time claim status updates, and aid in early error detection.

Are you facing challenges with the health of your revenue cycle? The following tips will guide you in refining processes, streamlining workflows in claim cycles, improving hospital revenue management methodologies, and keeping patient satisfaction at heart.

Understanding the significance of claims management and reimbursement in the healthcare revenue cycle is vital. Managing this process precisely helps maintain healthy operating margins for hospitals. Undoubtedly, effective administration encourages better financial health within these institutions.

Additionally, it adds to patient satisfaction by minimizing billing errors or delays and ensuring smooth transactions between patients, providers, and insurance companies, all contributing to an optimized healthcare system.

Hospitals and private practices approach revenue cycle management differently. Hospitals tend to have larger teams and intricate procedures while juggling multiple insurance carriers. Private clinics usually manage simpler cases with fewer resources available.

Each has unique challenges in achieving an efficient claims processing operation that enhances the flow of reimbursements without compromising patient care quality.

Healthcare Revenue Cycle Management faces numerous challenges, including complex and evolving regulations, billing and coding errors, variations among payers, slow payment processing, data security concerns, and rising patient financial responsibility.

Additionally, denial management, revenue leakage, manual processes, staff turnover, patient education, technology integration, and market competition contribute to the complexity of RCM. Addressing these challenges requires a multifaceted approach that includes process improvement, technology adoption, staff training, and compliance commitment to ensure the financial health of healthcare providers.

To enhance claims management, first analyze your current status. This requires examining three key aspects: the financial, technical, and operational sides of your organization. Understanding reimbursement metrics, evaluating systems involved in patient interactions, and assessing staffing and vendor relationships are all vital steps in formulating an effective remediation roadmap.

The first step involves patient registration and insurance verification. You confirm not only patients’ identities but also their coverages during this phase. Gaps here may lead you down the wrong paths later on.

Additionally, ensure accurate coding at every stage of service delivery. Using incorrect codes will likely delay payments or cause denials from insurers altogether. Submission speed is another critical factor when trying to collect quicker reimbursements.

Submitting your documents promptly often results in quicker returns. Taking the time now to ensure everything is accurate will help minimize any future claim issues and maximize your facility’s revenues. Ultimately, this will improve financial health for healthcare organizations like yours.

To enhance your data analytics capabilities, focus first on accurate data input. Remember that you can’t get precise insights from fuzzy details. Invest in advanced systems for patient registration and information collection to gather complete, accurate records at the source.

Next, train all team members thoroughly in coding accurately. This step will prevent misclassifications of diagnoses or treatments, often leading to claim denials.

Staying on top of your analytical software upgrades for optimal performance is important. Updating your software will help you predict trends more effectively by analyzing past patterns and improving accuracy in submissions. This proactive approach helps ensure long-term positive results.

To streamline your healthcare revenue cycle, consider implementing automated reimbursement solutions. They automate the billing process and can significantly reduce manual errors resulting in denied claims. Apart from reducing human error, this also frees up valuable time for staff to focus on more strategic tasks such as patient care.

Modern technology aids improved accuracy by flagging potential issues before claim submission. Simply put, effective automation means fewer obstacles when you seek compensation for services provided. Furthermore, automated tools yield real-time analytics, providing actionable insights into payment trends or discrepancies within your system.

Focus on precisely refining coding practices. Remember that accuracy is key in healthcare billing codes; any error can lead to denials or delays in payment. Invest time and resources to continuously train your coders to remain current with ever-changing medical terminologies, rules, and regulations.

Adopting a proactive approach ensures correct patient data input from the start, reducing rework significantly. Audit regularly for quality and efficiency; it’s necessary to spot flaws early while ensuring streamlined operations.

Utilizing technology to monitor payment postings is vital in refining your revenue cycle. When you harness tech tools, they can offer accurate tracking of payments, be it from private payers or public health programs like Medicare and Medicaid, effectively minimizing the instances of overlooked reimbursements.

Using digital platforms offers a major benefit: the capacity for real-time updates. This means no changes can slip through unnoticed; you’ll be aware of any alterations as soon as they occur. Furthermore, tools such as advanced billing software will instantly flag discrepancies, identifying any irregularities before they worsen.

To optimize revenue cycle outcomes, organizations need a solid grasp of analytics. Data-driven insights help identify trends and utilization opportunities. By understanding attending physician activities, diagnosis codes, or DRG tendencies, healthcare entities can make informed decisions.

This helps capture earned revenue compliantly while maintaining excellent care standards for patients.

Recent trends in healthcare claims management and reimbursement encompass several key areas. Automation and artificial intelligence are on the rise, with healthcare providers increasingly using these tools to expedite claims processing, reduce errors, and enhance overall efficiency. Additionally, the integration of telehealth into revenue cycle management processes is becoming commonplace, reflecting the shift toward virtual care.

This helps capture earned revenue compliantly while maintaining excellent care standards for patients.Value-based care models continue to gain traction, emphasizing outcomes-based reimbursement rather than fee-for-service, while improved data interoperability facilitates seamless claims management. Staying compliant with evolving billing regulations is a continued focus, alongside adopting predictive analytics to foresee and prevent claim denials.

These trends collectively aim to improve the efficiency and accuracy of revenue cycle management, aligning it with the evolving healthcare landscape and ensuring both healthcare providers and patients benefit from more streamlined processes and better financial outcomes.

At Brundage Group, we offer the technology to aid in revenue cycle management. Our expertise helps minimize denials and ease financial operations in revenue cycle management, a must-have solution for any medical facility aiming to enhance efficiency while delivering superior patient care.

It plays an essential role in maintaining cash flow stability, which is quite significant when success hinges on healthy finances.

As an integral part of medical billing, denial management unlocks and resolves issues causing claim denials. This approach isn’t about merely identifying errors; it aims to lessen the chances of future rejections.

By keeping an eye on evolving trends, they spot possible inconsistencies within patient registration, billing cycles, and medical coding—all factors contributing largely to denied claims. Appropriate scrutiny into individual payers’ payment patterns offers clarity over any deviations from standard procedures—a crucial aspect warranting careful attention under effective health administration standards.

Guarantee successful appeals for your future claims by mitigating potential pitfalls today! With ever-increasing denials (around a 20% increase industry-wide in recent years), adopting proactive strategies is imperative.

In exploring the denial management process, understanding various types of claim denials is vital. These refusals can originate from diverse areas, clinical or administrative. At times, they arise due to deemed unnecessary procedures by unqualified physicians from a medical standpoint.

On other occasions, office mismanagement leads to these rejections. Claim denials also cause delays in cash inflow and lost labor hours. In the worst cases, they even include uncompensated care provision!

Notably, there has been an alarming 20% increase across industries within five years, necessitating proactive positioning and effective strategy formulation for financial sustainability. A smart refusal administration approach helps decipher the underlying reasons behind rejected claims, enabling rectifying steps that might eradicate future occurrences.

So, engaging HIPAA-compliant tools while implementing systematic processes proves crucial for managing insurance plea turndowns effectively.

Stellar denial management in healthcare dictates faster reimbursement, which is vital for any practice’s financial health. You run the risk of slowed-down cash flow without a robust system to tackle claim denials. Identifying repeat instances of denial codes can offer insights into the areas that need improvement.

Monitoring these patterns helps uncover issues with medical coding or patient registration hindering successful claims appeals.

Moreover, keeping an eye on individual payers’ payment trends allows for easier identification when they deviate from normal behavior. Addressing clinical-related claim denials, such as non-essential procedures and unqualified physicians, also comes under this crucial process’ purview.

By proactively tackling such scenarios, you’re not just mitigating immediate losses but ensuring smoother operations in future billing cycles. In summary, integrating effective tools into your strategy facilitates revenue cycle challenges reduction by learning about the high-denial-rate root causes and contributing factors.

Thus, it shines a light upon why keen attention toward thoroughgoing denial management remains indispensable in today’s healthcare landscape.

To optimize your denial management process in medical billing, certain key components must be functional. A robust system for tracking denials is pivotal; this tool should monitor the date and type of each claim rejection, among other crucial figures, to pinpoint recurring issues.

Secondly, an efficient appeals procedure is vital to ensure successful appeal results and, as a result, quicker payment from insurers. Swift corrective measures can be implemented to facilitate this process. Automation can play an important role by handling paperwork and reducing the workload of staff members involved in claims processing.

Training also makes another essential element; well-geared teams at different stages handle their roles competently, cutting down on errors that could result in future rejections.

Implementing preventive strategies such as routinely revising processes or adjusting workflows can reduce potential setbacks, improving cash flow. Careful planning into these aspects helps to ensure smoother operations within healthcare facilities. This fosters stronger relationships between providers and payers, minimizing future denials significantly.

Firstly, you should scrutinize denials without delay to evaluate recurring patterns or reasons for rejection. This timely evaluation can prevent future claim rejections and significantly improve your revenue cycle outcomes.

Secondly, ensure you know each payer’s protocols, as they differ extensively. Insights into these guidelines will help assure adherence, reducing chances of denial. It is also essential to provide ongoing training to staff on coding updates and billing standards. An error in this area may cause a declined claim.

Finally, constant communication within all sectors involved, like insurance representatives, aids understanding and minimizes errors leading to rejections.

Remember that even minor improvements made through adhering diligently to these key strategies improve collections while ensuring quicker payments from payers, thus enhancing overall financial health!

By partnering with Brundage Group, you position your healthcare organization for success. Our expertise lies in revenue cycle management analytics, which enables us to offer actionable insights vital for optimizing financial operations. We adopt a data-focused approach that empowers hospitals like yours to successfully navigate the intricate landscape of revenue cycles.

We also provide customized solutions catering precisely to your needs and objectives related to revenue cycle managing tasks. A notable trait is our unique knack for identifying negative trends before these can crucially affect critical aspects such as Medicare Advantage payers.

Moreover, our commitment to excellence is clear: we provide high-quality service while ensuring compliance throughout all processes. This demonstrates that excellence isn’t simply rhetoric but true action.

Remember that an efficient denial management process can make or break your practice. Harnessing competent personnel, investing in technology, and ensuring stringent follow-ups are key steps on the journey towards reducing denials.

Denial management centers around navigating and resolving unpaid medical claims. Often, denials occur for various reasons. Firstly, gaps in data can cause claim refusal, with a whopping 42% of denial write-offs resulting from missing information; just one unfilled required field might lead to such an outcome.

Secondly, duplicate submissions are a common cause of denials. This occurs when the same service provider registers identical details for the same patient procedure or service item on the same day. This is especially true for Medicare B, which has an occurrence rate of over 32%.

Then there’s adjudication-related rejection, which occurs when payment benefits from another pre-settled procedure or service cover specific services offered, resulting in a denial. Further along are non-covered procedures, where if any process falls outside coverage within your current benefits plan, you face the potential risk of claim repudiation.

Lastly comes submission deadline-related exclusions; missed timelines could counteract successful filing, leading to a denied case scenario.

Despite our best efforts, human error does happen. Typos or incorrect data entries are common culprits. Leveraging modern technology like automated software can make all the difference at this denial management strategy implementation stage.

Software tools perform thorough checks against set parameters on every single piece of information within a claim form to ensure its validity. These parameters include patient demographics, insurance policy numbers, and codes related to procedures conducted or medications prescribed—just about anything you’d see on an insurance company’s radar while examining healthcare claims. You also need expert hands who will step in wherever automation fails!

Continual professional development plays a significant role here, enabling staff with evolving industry standards and guidance around recent policy changes from insurers, paving the way towards improved success rates! Remember, prevention outweighs cure when it comes to denied medical claims!

Understanding the pattern of denials plays a key role in managing earned revenues effectively. You must delve deep into your denial reports, pinpointing specific causes leading to most claim refusals. Typically, you’ll find a small fraction of issues causing the bulk of your difficulties, confirming the 80/20 rule.

Address this problem by studying these recurrent patterns vigilantly and focusing on reducing them one at a time. This method allows for gradual yet impactful change within your operations while boosting staff morale as they witness tangible improvements resulting from their efforts. Enhancing patient-facing administration with periodic training can help counter frequent errors too.

Since accurate billing commences with the first patient contact, assuring top-notch data collection upfront translates into immense downstream benefits. As schedulers obtain or confirm insurance details during calls, an integral responsibility, verifying eligibility prior to or post-appointment, is wise too! Keen analysis and focused action create powerful changes, improving reimbursement rates and overall stability.

As you delve deeper into denial management, another vital step is refiling appeals with supporting evidence. This process ensures that no claim goes unpaid due to a lack of proper backing data and documentation. Medical coding systems can be complicated, leading to errors and issues that slip through unnoticed.

When a payer denies your claim on grounds such as insufficient proof or incorrect code usage, don’t give up right away! Gather all relevant documentation, such as diagnosis records, course of treatment details, or doctor’s notes showcasing medical necessity for the services rendered. Once compiled and reviewed by an in-house team or an outsourced billing service provider, refile those denied claims immediately!

Clear communication is paramount between care providers, billers, coders, and payers. Addressing denials effectively shows clear signs toward financial wellness in the long run of hospital system operations across the U.S. today!

Once your appeal has been lodged, keeping track of its progress is vital. Don’t let open cases fall by the wayside. Regularly check up on each one’s status with your payer contacts.

With this consistent oversight, you can uncover if any information or action from you might speed things along. Moreover, ensure proper documentation for every case under review. Not only does it justify an appeal, but it also guides future steps should a denial occur again in similar scenarios.

Lastly, consider using specialized software that aids in overseeing and managing these tasks more effectively. Technology can become a valuable ally, providing regular updates about pending cases without requiring human intervention all the time. Keeping abreast of open appeals allows for swift redressal, ensuring smooth revenue flow into your healthcare organization and contributing to operational efficiency simultaneously.

Developing action plans is crucial as you move forward. You’ve already worked on identifying the root causes of denials; now it’s time to resolve future ones.

Implementing an effective course of action entails several steps that must be followed consistently. Collect comprehensive data from previous denials as a basis for analysis and understanding of potential pitfalls. Next up, build competent teams who understand their roles clearly in the prevention process and can address issues efficiently when they arise.

Encourage open communication channels to enhance synchronization between different stages of revenue cycle handling processes. Focus attentively on accurate documentation; remember, medical coding also plays a vital role here! It could secure claim approvals effortlessly if done right.

Lastly, automate whenever possible using smart technology tools like AI-based claims scrubbers or predictive analytics engines, which help prevent errors before submission. Remember, these strategies aren’t one-time fixes; they’re ongoing efforts requiring diligence that will ultimately boost financial health significantly.

Ensuring a smooth flow in denial management can be taxing. But you’re equipped to handle it effectively. Our services and proprietary technology platforms provide solutions for identifying problem areas and implementing effective denial management strategies.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

Is your hospital receiving a high volume of clinical validation denials? If so, you’re not alone.

Clinical validation denials continue to grow in volume and many organizations remain vulnerable to them. Clinical validation was defined with the 2011 Recovery Auditor (RA) scope of work as a separate process from DRG validation, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented.

Does your organization have a clinical validation process in place, and if so, it is as robust as your DRG validation process? If not, why not?

When Coding Guideline 19 for Code Assignment and Clinical Criteria was introduced, there was a corresponding Coding Clinic that included some key concepts related to how this guideline should be interpreted. These included the following:

1. Although ultimately related to the accuracy of coding, clinical validation is a separate function from the coding process.
2. If the physician documents sepsis, and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician’s diagnosis that is a clinical issue but is not a coding error.
3. A facility or payer may require a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but hat is a clinical issue outside of the coding system

So, who in your organization is responsible for clinical validation? It is not a coding function, but has your organization embraced it as a clinical documentation integrity (CDI) function and dedicated the resources necessary to develop a robust clinical validation process?

I know many organizations have implemented organizational definitions for diagnoses vulnerable to clinical validation like sepsis, acute respiratory failure, malnutrition and others, but organizational definitions are not enough to create a robust clinical validation process. Ironically, my company often sees clinical validation denials associated with diagnoses that were added through a CDI query at a healthcare organization with organizational definitions.

You see, it starts with fundamentals. What is the goal of the CDI department? Is it really documentation integrity and accurate reimbursement? If so, why as a CDI professional don’t we have a defined processes of what to do when a diagnosis isn’t clinically validated but a code is assigned? Is it enough to query to ask if the diagnosis was ruled out?

There are so many gaps in the clinical validation process on the hospital side that need to be addressed it is no wonder that payers are taking full advantage.

By: Pamela Bensen, MD, MS, FACEP

Emergency departments (EDs), the US healthcare system “safety net”, are seeing sicker patients as the “less sick” are routed to offices and urgent care. This concentration of complicated patients requiring more extensive workups and treatments has increased the percentage of Evaluation and Management (E/M) level 4 and 5 visits.

UnitedHealthcare (UHC), whose stock has gone up 1000% since 2010, conducts ED coding, documentation, and claim reviews via its wholly owned subsidiary, Optum Payment Integrity. Despite appropriate documentation to support the complexity of the E/M codes submitted, Optum denies payment for ED services. Written appeals that support the original code(s) are almost universally denied, with UHC refusing to pay for ED services, or paying the claim at a reduced level.

Denials are due to Optum’s software algorithms that use the final ED ICD-10-CM diagnosis codes to determine the E/M code. However, the AMA’s Current Procedural Terminology (CPT Manual) and the CMS 1995 Documentation Guidelines for Evaluation and Management Services (DGs) clearly direct that determination of the proper E/M code for emergency medicine encounters is not based on the ICD-10-CM code, but instead requires a combination of three key components:

• History
• Physical Exam
• and Medical Decision Making

And, the level of each of these key components should only be based on the Medical Decision Making defined as, “the complexity of establishing a diagnosis and/or selecting a management option as measured by”:

1. Number of possible diagnoses/management options considered;
2. Amount/complexity of medical records, diagnostic tests, other information reviewed and analyzed; and
3. Risk or significant complications, morbidity, mortality, and comorbidities, associated with the patient’s presenting problem(s), diagnostic procedure(s) or possible management options.

After a four year battle, in a September 16, 2019 letter (read original here), the American College of Emergency Physicians (ACEP), representing 40,000 emergency physicians, and the Emergency Department Practice Management Association (EDPMA), representing about half of the 146 million patient visits to US EDs, notified UHC that they are advising their members that all necessary and appropriate legal action should be considered, including litigation addressing non-payment for services rendered. Copies were sent to federal and state officials and U.S. Senators and Representatives.

State PLP laws that apply to state regulated health plans. For additional information visit: https://newsroom.acep.org/2017-06-09-prudent-layperson-standard

CMS letter from April 2000 clarifying the definition of PLP in the BBA of 1997: https://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd040500.pdf

Federal Register Nov. 10, 1999 (Vol 64, No. 217) page 166 link

The National Association of Healthcare Revenue Integrity (NAHRI) recently asked our medical director, Dr. Tim Brundage, for his insight on Medicare Advantage denials. Click to read the complete NAHRI Journal article, “Take control of Medicare Advantage denial challenges”.

“It isn’t surprising that MAOs are looking to make a profit; after all, they are private companies. But the implications of denying or delaying medically necessary treatment to cancer patients while offering benefits such as high-tech fitness trackers raises reasonable concerns about how some MAOs are using federal money, says Timothy Brundage, MD, CCDS, medical director of The Brundage Group in St. Petersburg, Florida. “They’re promising all the bells and whistles. The only way you can provide bells and whistles is if you’re actually saving cost, and the way to save cost is to have the care of the patient be lower than the expected cost of caring for the patient,” he points out.

In theory, MAOs will keep patients healthy by encouraging them to make use of lower-cost outpatient services such as regular primary care checkups. In turn, MAOs are encouraged to keep patients healthy and out of the hospital through risk-sharing and capitated payments. However, as the OIG report pointed out, that can incentivize MAOs to deny or delay medically necessary care that can only be provided in a hospital. “The biggest-ticket item that you have as a risk dollar is an inpatient hospitalization. That’s a super-expensive place to receive care, and obviously that patient is very sick if they get admitted to the hospital,” Brundage says. “The managed Medicare folks do everything in their power to keep the patient in observation or outpatient so they’re caring for their patient at the lowest cost possible.”

By: Michael A. Salvatore, MD FACP CHCQM, Physician Advisor

Suggestions for conducting peer-to-peer appeals for denials

If you are wondering why you should read this if you think you are not a rebeginner, well, it is because you actually are one. Beginnings do not disappear, they just reproduce. Novices are just starting, veterans have started over and over. We all begin as beginners and then we begin rebeginning.

So as a perpetual rebeginner, I would like to share some of my ‘relearnings’ about doing peer-to-peer (P2P) appeals for insurance denials:

1. Insurance denials are not personal, so don’t take them personally. Why was best answered years ago by Michael Corleone in the Godfather trilogy, “Don’t hate your enemies, it affects your judgment.”

2. Many denials are made on incomplete clinical information. The peer often doesn’t know the whole story. Get the whole story and tell it vividly – this may be the first time the peer is hearing it, so make it cogent.

3. Recognize that some denials are appropriate denials and learn from them. Use them for ‘Teachable Moments’: Why the INPT should have been OBS. Why the documentation was inadequate. Why the patient should have gone home from the ER. Consider insurance denials as a painful form of clinical documentation integrity (CDI).

4. Do NOT just repeat the clinical record; present YOUR review of the whole clinical record.

5. Read the nursing notes.

6. Do NOT be limited by the current hospital record. If a patient was admitted with an elevated creatinine but no prior creatinine is referenced in the H&P – look it up. Old labs can result in overturns.

7. NEVER take a Progress Note as the whole story, very often today’s Progress Note is yesterday’s note or even the day before that – pay attention for poorly or unedited copy/pasting.

8. Always review the all vital signs yourself. Look for abnormal VS not mentioned in PNs. If you are not metric-minded be careful: 37.7O C looks innocuous but it is 100O F!

9. Always thoroughly review the MAR. Look for PRN aerosol Rxs and PRN IV medications, etc. They may not be in PNs but can contribute to severity of illness.

10. If the peer refuses to overturn the denial, ask why. An effective strategy is to inquire what would have made the case INPT. Sometimes in the discussion you find the something you need to get it overturned. Get the peer talking Medicine.

11. Keep records of which doctors are having their cases denied – give them 1:1 feedback but also present the feedback at departmental meetings unblinded.

12. Track denials by provider and reason, know what insurers are doing what.

13. Study your peers – learn their style. Know who will consider the whole clinical picture and who will strictly adhere to MCG or IQ.

14. Know the contract your hospital has negotiated with the insurer, e.g., does it allow for combining repeated admissions within 30 days. Never take the insurer’s word for it.

15. Know if the MA insurer has a contract, if not it defaults to traditional Medicare guidelines.

16. If the peer upholds denial just because it was only 1 MN but met their criteria (MCG or IQ) take it to their Medical Director, review the contract, and if necessary, appeal to the Centers for Medicare & Medicaid Services (CMS).

17. When in doubt – always appeal.

18. Always be gracious in defeat but know your appeal rights in your contract.

19. Doing Multidisciplinary Rounds and doing P2Ps are synergistic.

Insurance details are opportunities, do not waste them. They are chances for PAs to learn about the state of documentation in their shop, about their staff’s comprehension of policies, e.g. Observation, and to keep up to date on clinical medicine.

Denials are also an opportunity to demonstrate the vital financial role of the PA in today’s hospitals and to this end:

20. Keep a detailed record of the denied charges you have recovered.

21. Do not keep #20 to yourself.

By: Trey La Charité, MD, FACP, SFHM, CCS, CCDS, Brundage Group Physician Advisor

DRG 853 Infectious and Parasitic Diseases with OR Procedure w/MCC is Under Attack!

Procedural titles should not be taken at face value! What the surgeon actually did in the OR may be different than what the surgeon said they did in the OR. If auditors can change the coding of a documented procedure from a valid OR procedure to one that is not, that kicks the case out of the 853-855 set of MS-DRGs, moving the case from a surgical DRG to a lower reimbursing medical MS-DRG.

Pay particular attention to the documentation of excisional debridement. This can be performed by physical therapists at the bedside and still count as a valid OR procedure regardless of performance location. Auditors/CMS/OIG are opposed to the idea that a bedside procedure bumps a medical MS-DRG to a surgical one.

If it can be traced/linked/ascribed to some previous medical intervention, the principal diagnosis should be the corresponding complication code, which may change the MS-DRG.

Remember that the chapter specific coding guidelines state that sepsis is the principal IF the reason for admission is both sepsis and a localized infection. If the patient came to the hospital for some other reason, and that reason is not attributable to sepsis, sepsis is probably not the correct principal diagnosis.

Auditors do not waste time reviewing charts with multiple MCCs or CCs. Therefore, make sure single MCC and single CC charts in the MS-DRGs 853 and 854 have rock-solid, consistent and repeated documentation throughout the record, including the D/C summary—and that definitive, clear, widely accepted clinical criteria thresholds were demonstrably reached.