Strategies to Overturn and Prevent Medical Necessity Denials

Hospitals and practices now face more cases where the care they give isn’t seen as needed, leading to lost money. Even though it’s hard work, these groups must fight back against such decisions. They need plans both to win back what was denied and stop it from happening again.

The key lies in understanding the rules set by those who pay for care, which includes big guidelines like NCDs and LCDs that tell when Medicare will cover services.

Strengthen Pre-authorization Processes

To make your pre-authorization stronger, first check all patient info is correct and up-to-date. Next, always confirm the need for a specific service with clear medical evidence. This shows why it’s necessary right from the start. Use current treatment guidelines to back your requests. This not only speeds up approvals but cuts down on rejections tied to questions of necessity. 

Keep track of all communications with insurers as proof in case you face denials later on. By following these steps closely, you can reduce delays and ensure patients get timely care without unnecessary hurdles or extra costs due to denied claims.

Improve Clinical Documentation

Focus on improving medical records. Many firms use a team to save significant time here. Clinical Documentation Improvement (CDI) checks if records are complete and correct, looking at illness details, test results, and any missing information.

A CDI expert knows healthcare and coding well. The aim is to align clinical notes with accurate coding. This means ensuring all, from providers to staff, understand documentation clearly, which might require basic retraining for some.

Mistakes inpatient data often lead to claim denials. Review intake processes if denials rise or persist consistently. This may signal issues needing swift corrections by front desk teams for future clean claims. Remember: proper paperwork shields against legal troubles over negligence allegations. 

Foster Payer Relationships

Focus on building strong relationships with payers. Understand their review algorithms and criteria for claims submission deeply. Engage in open dialogue to clarify any complex terms or specifications that could lead to misunderstandings and, ultimately, claim rejections.

Regularly update your team on changes in payer contracts and policies that might affect claim approvals. Ineffective communication often results in denied claims linked to prior authorization issues, a significant factor leading to increased denial rates from 10% to 11% between years, alongside the substantial growth of unpaid claims reaching over $100 million for many hospitals. 

By fostering better engagement with payers, anticipate fewer unnecessary denials, which currently stall accounts receivable by at least two weeks per instance and impact patient care negatively due to secondary costs or delayed treatments ensuing from those financial disputes.

Utilize Denial Management Software

Use denial management software to pinpoint and fix the reasons behind your denials. This tool helps you understand why claims get denied, focusing on specific facilities, providers, payers, or procedures causing issues. By identifying these root causes, your team can make necessary adjustments to stop future denials.

With 85% of denials being avoidable and a 41% reversal rate for appealed ones, it’s clear that proper management could save significant money, up to $11,700 monthly, if you’re appealing just 100 denials. Effective use ensures timely payments from insurers while letting healthcare professionals concentrate on patient care.

Establish a Dedicated Denial Management Team

Form a team focused on denial management. This group uses automated systems to track and address denials swiftly. Their work boosts staff efficiency by allowing for quick responses like appeals or corrections. They also use data analytics to spot trends in denied claims, leading to fewer future issues. Having this dedicated team ensures that all steps, from verifying patient details before service to appealing unjust denials, are handled promptly and effectively, maximizing reimbursements and improving financial outcomes for healthcare providers.

To stop and fix medical need denials, Brundage Group suggests clear plans. First, ensure records are full and clear before sending them to insurers. Next, train your staff well on billing rules and updates.

Then, use data to spot trends in denials. This helps find where improvements are needed most. Finally, a quick follow-up on denied claims is key to getting issues sorted quickly. By following these steps closely, healthcare providers can cut down on lost earnings due to needless claim rejections while improving patient care quality at the same time.

Comments are closed.