Articles Tagged With: denials
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Payers, Hospitals Disagree About Whether Patient Meets Inpatient Criteria
Payers are refusing to pay claims for gastric bypass, joint replacement, and even cataract extraction. Why? Because documentation in the record does not support the need for surgery.
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Missing Clinical Documentation Reason for Many Claims Denials
More health plans are asking for certain pieces of clinical documentation before paying claims. If it is not there, the claim is denied. What are the specific issues arising?
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‘Uncollectible’ Claims Just Need Fresh Approach
Stat diagnostic tests are triggering claims denials because payers dispute the urgency. This article discusses steps patient access can take to increase the chance of a successful appeal.
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Provide Indisputable Proof: Patient Meets Criteria for Level of Care
Increasingly, payers are disputing the patient’s level of care, resulting in denied claims. This article discusses ways to help prevent lost revenue.
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Auth Doesn’t Match Service? Expect Claim Denial
Claims denials often occur as a result of “mismatches” between what was ordered or scheduled, and what actually was done. This article discusses how to ensure payment.
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Is Imaging Test Needed ‘Stat?’ Don’t Risk ‘No Auth’ Denial
Payers increasingly are denying claims for “stat” imaging because of no authorization. This article describes practices that can help avoid problems.
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Take a Proactive Approach to Managing Denials Before They Occur
If hospitals are doing only denials management and not avoiding denials up front, they’re already behind, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.
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Auth in Place, Then Different Procedure Is Done? Avoid “No Auth” Claims Denials
When a physician orders a procedure to be performed in a surgical setting at Birmingham, AL-based UAB Hospital, patient access staff start the process of obtaining required authorizations.
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Payers claim procedures weren’t medically necessary
With medical necessity denials, “prior authorization is ‘job-one,’” says John Holyoak, director of product management at RelayHealth Financial, which is based in Alpharetta, GA.
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Did payer deny claim? Look closely to see if contract allows it
Many patient access leaders are seeing a sharp increase in claims denials, primarily due to more numerous and stringent payer requirements.