By Melinda Young


The keys to preventing and overturning payer denials are to collect data to identify problem areas and to train staff in best practices.

  • Missing or hidden lab data could result in a claim denial.
  • The case management team should understand the information each payer wants and how best to share those data.
  • Spoon-feeding information to payers’ utilization review nurse is one good method.

Through training and following best practices, case managers and utilization reviewers can prevent and overturn payer denials.

Often, a denial results from omitted information. “It could be the low-hanging fruit of ‘We didn’t get the data we were needing, so we denied it,’” says Hemant Gupta, MD, MSc, lead national physician educator with Sound Physicians in Tacoma, WA.

The easy fix is to send them the missing information. The long-term, preventive answer is to find out why the information was incomplete. “Try to understand that there are many, many hands that cross this pathway,” Gupta says. “If it’s not a reliable pathway of crossing, the data doesn’t get there.”

Breakdowns in data exchange between health systems and payers occur when vital parts of the medical record, which were extracted in PDF, faxed, or emailed content, lack essential data.

“Say I had to diagnose a heart attack, but the labs weren’t there,” Gupta says. In that situation, the payer did not receive the appropriate lab work that documented proof of the heart attack diagnosis.

“Lab information didn’t get to the utilization review nurse or doctor, so they didn’t approve it,” he adds. “This is not about just sharing information or giving electronic medical record access. There are different health systems and different levels of workflow for health information management and case management people.”

The long-term solution is to collect information on how often denials occur due to particular issues, such as missing data. For instance, it could be that six times in the past month, data did not reach the right decision-maker, leading to a denial, Gupta explains. “Chalk that up to a complicated pathway and simplify that pathway.”

Case managers and those in charge of UR should understand what information each player wants and how best to share data. Preventing denials takes less time and fewer resources than trying to overturn a denial. It is important to know a particular payer needs specific information highlighted in the data submission, or the overworked person receiving the information may miss something important to preventing a denial.

“As you discover documentation holes in the electronic medical record, you should be bringing this issue to the people doing the documenting,” Gupta says. “You have to have an expert who knows how to read the record, has clinical knowledge, and who knows what data and criteria they rely on. It can’t be just any person.”

Ideally, the team should work well enough to meet all time-based deadlines and handle appeals. “Unless you have a dedicated team of people who know what they’re doing, that gets to be a very sizable task for a case manager,” Gupta says. “They have several daily activities they do in discharge planning, and it gets to be a very burdensome process, unless you have a dedicated team that is capable of handling it at an expert level.”

For example, a patient with COPD can be hospitalized under appropriate medical necessity guidelines. A common question is why a COPD patient needs additional medical care on day two or three of the hospital stay. Are these additional hospital days medically necessary? How can the hospital prove it? Where is the documentation?

“For COPD patients, certain lab results are very important to get printed out and documented in the record, and they have to be reported in a certain way,” Gupta says.

If the essential lab results are buried in 50 pages of lab results, it is like finding a needle in a haystack. “This specific lab [result], if present, can easily be found and could overturn a denial,” Gupta says.

The payer’s staff review dozens of cases each day and are sifting through volumes of information. It helps if health providers highlight the essential data, making it easier to find. “This can be a very tiring day for a case manager, on the insurance side, and also on the hospital side. You need relevant, critical information to make the right decision,” he explains.

It is up to case management/UR leaders to teach staff the relevant and critical pieces of information and how to send this information in a timely manner. If it is done correctly, they will win the case, even if it is denied.

“Many times, you will not get a denial because they found the data they were looking for, such as the amount of CO2 dissolved in blood of COPD patients and that was elevated beyond a specific amount,” Gupta says. “These data are important in a discussion of how sick the patient is and how the patient should be in the hospital instead of being discharged.”

When this critical information is missing or buried in documentation, the risk of denial increases. Spoon-feeding information to the payer’s UR nurse is a great way to reduce barriers and denials.

“Every time you do that and let the light happen at the end of the tunnel, it gets clearer and clearer,” Gupta explains. “You learn case by case.”