More health plans are asking for certain pieces of clinical documentation before paying claims, according to Rajiv Sheth, director of Navigant’s revenue cycle management consulting team. If it is not there, the claim is denied. What are the specific issues arising?

Health plans want to know the patient has tried cheaper alternatives before approving surgery. “Payers want evidence the patient has completed a specific amount of time on ‘conservative treatment,’” Sheth says. They often want proof the patient tried physical therapy or medications before surgery.

On the inpatient side, payers are denying claims because provider documentation is either not a definitive diagnosis or does not support severity. The use of terms such as “likely,” “impending,” and “suspicious for” are causing payers to question necessity, Sheth observes.

ED services may be denied for nonemergent diagnoses. This might be for something such as an upper respiratory infection.

Payers are denying claims because documentation does not support the diagnosis. A common example is a dehydration diagnosis, but the patient was treated with short IV infusion, and is on oral intake the next day. Payers also deny claims with a sepsis diagnosis if labs or cultures are within the normal range.

Payers are denying short stay inpatient bills. The health plan claims the patient could have been treated in an outpatient setting. Case management or use management nurses can help with this by ensuring inpatient admission orders support the patient’s status as an inpatient.

Not all claims denials give a specific reason, making it difficult to correct. “Patient access should be prepared to receive denials with incomplete or insufficient explanation from the payer,” Sheth cautions.

Health plans are scrutinizing coding, says Shela Schemel, senior vice president of Navigant’s business process management team. Claims are returned for reasons such as “bilateral diagnosis not used” or “incorrect laterality with procedure.”

Even claims that are denied for “medical necessity not met” often can be traced to incorrect coding. “Many times, this is still coding,” Sheth reports. “Incorrect coding can create a domino effect of payer denial reasons.”

It would be easiest for patient access to submit all relevant clinicals at the same time as the claim. Health plans use a different process. “When it comes to clinical documentation, payers don’t always want all that paperwork up front,” Sheth explains. Instead, a back-and-forth process is used. First, payers receive the claim, then they request medical records (if necessary).

To avoid payment delays and denials, Sheth recommends compiling all clinical documentation so it is ready to go. “Anticipate that payers will request it at any time,” Sheth says. Also, add a note to the claim stating, “Additional information available upon request.” With good clinical documentation, many denials can be appealed successfully.

“They are hoping you don’t fight them back. Don’t just accept the first denial if you believe the claim should be paid,” Sheth advises.