Denials Management: Tips for a Successful Appeals Process
While the focus should be on denial prevention for maximum reimbursement, some denials are inevitable, hence the need for hospitals to have a strong appeals process. Appealing denied claims is another strategy to beat the payers at their own game. Having a dedicated team with the clinical expertise to overturn denials and recover additional revenue is a must. So, what are some tips for increasing a hospital’s appeals success rate?
Perform Concurrent Reviews
The appeals process needs to start with concurrent reviews while the patient is still in house. Case Managers or Utilization Review (UR) nurses send clinical reviews to the payers and are notified if the payer “intends to deny” due to the patient not meeting medical necessity. The UR nurses then must decide if they “agree” or “disagree” with the denial. If they agree with the denial and deem it non-appealable then the hospital should bill the claim as an outpatient to receive payment on all ancillary and Emergency Room services. If they disagree with the denial, then the UR nurses submit an appeal.
Hospitals should highly encourage the involvement of the attending physician and/or physician advisor in the concurrent review process. When a denial is deemed appealable by the UR nurses, engaging the attending physician and/or physician advisor in a peer to peer review with the payer may help in overturning the denial without having to submit a formal appeal. Including the physicians in the concurrent review process also provides an opportunity to educate them about medical necessity denials and the appeals process. When physicians are educated and understand the financial impact of denials to the hospital, they will buy-in and lend their support.
Review Payer Contracts
Payer contracts tend to include various stipulations that make preventing and appealing denials quite challenging for hospitals. Reviewing the contracts for the addition of friendlier language, addressing medical necessity denials and appeals, can allow for expedited appeals and faster reimbursement. Seeking help from other hospitals on lessons learned or specific verbiage to include is highly recommended. It never hurts to ask.
A successful appeals process doesn’t just happen. It takes a coordinated effort by a dedicated team consistently analyzing denials and monitoring submitted appeals. When an appeal is upheld or overturned, a lesson is to be learned to ensure future appeals success. Whether it is a full or partial denial, if it is worth appealing, appeal it. Some money is better than no money!
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