Skip to main content

All Access Subscription

Get unlimited access to our full publication and article library.

Get Access Now

Interested in Group Sales? Learn more

Articles Tagged With: denials

  • Case Management at the Entry Points: Ensuring Reimbursement Through Appropriate Surveillance

    At a time when capacity and reimbursement are more important than ever, case managers play a key role in helping operations run smoothly. One way this happens is through monitoring the entry points of the hospital. These points include the emergency department, post-anesthesia care unit, direct admission to the units, or transfers from other facilities. This is not to say case managers should now add “security guard” to their extensive list of roles and tasks; rather, they are uniquely positioned to survey the whole picture, including how entry points are used.
  • Best Practices for Managing Denials

    When denials occur, case managers should create a plan to investigate and manage each one to determine why the claim was denied and how they can help. Using this approach, some managers have uncovered trends and root causes that can prevent future denials. It is critical for case managers to hone this skill for the benefit of the patient and the hospital.
  • Denial Prevention Tactics Are Front End-Focused

    Revenue cycle departments spend lots of time and money appealing denied claims. However, some hospitals are diverting resources to the front end instead.
  • Target Low-Hanging Fruit in Preventing, Overturning Denials

    The keys to preventing and overturning payer denials are to collect data to identify problem areas and to train staff in best practices. The case management team should understand the information each payer wants and how best to share those data.

  • Understanding Medical Necessity Improves Utilization Review Process, Reduces Denials

    The case management team should be trained thoroughly on utilization review and medical necessity to avoid payer denials. The goal is to ensure patients receive medically necessary, high-quality care.
  • Survey: Prior Authorization Hassles Persisted Mostly Unabated Through 2020

    A public health emergency did not seem to remove many bureaucratic roadblocks, to the frustration of U.S. physicians.

  • If CPT Code Changes, Patient Access Can Obtain Payment

    Patient access can intervene to stop an unauthorized test, assuming it is not emergent or urgent — or find out if the patient wants to go forward anyway. Registrars' expertise makes all the difference on whether the hospital is paid, and how quickly. Possibly, the health plan will agree a new authorization is unnecessary — as long as the clinical records are sent with the claim.

  • Revenue Depends on Correct CPT Codes; Beware Sudden Changes

    The revenue loss caused by CPT code changes is nothing short of staggering. When it comes to CPT codes that change after service, one of the biggest challenges is in the surgical space. Learn how some patient access departments are proactively addressing this problem.

  • Data Are the Key to Avoiding Claims Denials

    Claims denials have increased by 11% nationally since the onset of the COVID-19 pandemic, according to an analysis. Almost half of claims denials are caused by front-end revenue cycle issues, including registration/eligibility, authorization, or service not covered. Implementing a process to check eligibility at multiple points throughout the revenue cycle will go a long way in preventing this common denial from occurring.

  • Centralized Utilization Management: The Good, the Bad, and the Best Practices

    Challenged with employing enough staff in case management departments, the need for expertise in every role, and the increased requirements from payers, case management leaders are evaluating centralizing utilization review. This centralization carries both benefits and challenges, some of which are amplified because of the current healthcare climate.