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UASI in JAHIMA: Top Ten Tips for Denials Management

It has become increasingly important for health information management (HIM) departments to have strategies for tackling denials management. It is in every organization’s best interest to develop a proactive approach to denials management. While many are already doing this work, consistent and constant management of the denials process is essential. The following list—while not exhaustive—includes 10 tips for effective denials management.

Tip #1: Appeal every case where there is documentation to support the original coding.

Every denial should be thoroughly reviewed for the validity of the denial and examine whether the documentation supports the original coding. The denial may be based on clinical indicators or a coding error and it is important to consider the content of the denial and the expertise necessary to develop an appeal.

That being said, not every case should be appealed. For cases not supported by documentation, the best course of action may be to not appeal and accept the denial. However, this does provide an opportunity to address any documentation or coding deficiencies in order to prevent future denials.

Tip #2: Seek clinical and coding expertise to write the appeal.

An organization’s denials management team may be located in the finance department and it is critical that clinical documentation integrity (CDI) and coding teams are involved in the review of these particular denials. Clinical validation and coding denials require the expertise of documentation and coding experts and these individuals should be part of any denials management team.

While having a single point person to address clinical and coding denials, there will be occasions where CDI and coding subject matter experts need to collaborate and lend their knowledge to the appeal writing process.

Tip #3: In the appeal, restate the reason for the denial from the original letter.

In the development of an appeal letter, restating the denial reason from the original letter provides additional information and a recap for the payer’s complete review of the appeal information. This also provides an opportunity to more clearly articulate the stance of the organization as it pertains to the denial.

Tip #4: Keep the appeal letter concise, factual, and specific to the reason for the denial.

Speak directly to the content of the denial. It’s important to resist the urge to put too much information into the appeal letter. It’s natural to want to provide a large amount of documentation in an effort to overturn the denial. However, doing so may work against the facility as the payer likely will not sift through a large amount of information and simply submit a second denial. Provide the facts without being verbose.

Tip #5: Include the pertinent record excerpts that support the appeal.

Most electronic records provide the ability to extract specific data from the documentation to support an appeal. Use this information to bolster the content of the appeal letter. For those excerpts included in the letter, provide specific context to support them and how it specifically relates to the denial reason and provides documentation for an appeal.

Tip #6: Include the complete report where helpful (e.g., an operative report).

There will be instances where a complete report needs to be included in the appeal to support the argument to overturn the denial. In these cases, be sure to reference the specific report in the body of the appeal letter and provide the appropriate context to support the information contained in the document. It’s also important that the individuals submitting the appeal letter know that the report should be attached to the appeal letter when sent.

Tip #7: Include official guidance (e.g., Official Guidelines for Coding and Reporting, AHA Coding Clinic)

This portion of the letter is crucial supporting evidence for an appeal letter; official guidance provides the backing necessary to support the information in the appeal letter. It is important to include official guidance only and ensure the interpretation of the guidance matches and bolsters the argument for the appeal. Recognized sources of official guidance for inpatient cases include: the ICD-10-CM/PCS code set, ICD-10-CM/PCS Official Guidelines for Coding and Reporting, and the American Hospital Association’s Coding Clinic publications.

Tip #8: Include the credentials of everyone involved in developing the appeal.

It is important for payers to understand the expertise of the individuals involved in the appeal process and to recognize that subject matter experts are actively participating in the thorough evaluation of the documentation and the development of the appeal letter.

Tip #9: Include a deadline for a response from the payer.

It is within the rights of a healthcare organization to request a deadline for a response from payers. A sample for this request may be stated as “If a response is not received by XX/XX/XXXX, we will consider the appeal accepted and the denial overturned.” Allow adequate time for a payer’s response.

Also, consider reviewing managed care contracts that might include language related to denials and the required response time. There may also be state regulations that govern response times, and these should also be investigated.

Tip #10: Require the payer to disclose the expertise of the individual(s) who determined the denial.

It is also within the rights of every healthcare organization to request a listing of the individual(s) involved in the denials process. This detail may also be provided in the language of managed care contracts. Commercial payer denials provide an opportunity to engage with the managed care team in the organization for a complete picture of these specific contracts.

A Robust Denials Management Process is Critical

Success can be measured through all types of metrics, such as total denials received, total appealed, cases not appealed and why, total cases overturned and associated financial impact, second-level denials, and failed appeals. It is important to document the data associated with any denials management program.

While not necessarily easy, a robust denials management process is critical during this time in healthcare. Documentation and coding are subjected to a significant amount of scrutiny from both governmental and commercial payers and it requires a specific expertise to support the process.

Click here to view the original article: Top Ten Tips for Denials Management | Journal Of AHIMA