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CMW Sneak Peek: Say yes to best practices in denial prevention

Case Management Weekly, October 15, 2008

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Today, hospitals are facing many challenges: Shrinking payer sources, increasing charity care, mounting bad debt, and the reduction of Medicare payments due to new initiatives—including recovery audit contractors and present on admission—give hospitals greater motivation to be on top of their game.

It’s no longer enough for case managers to do things as they’ve always done them. Case management is now a key element in implementing strategies to reduce denials and keep the fiscal viability of the hospital intact.

The two common types of denials are:

Technical denials. These frequently occur when the facility is unable to verify a patient’s insurance upon admission, when the patient does not have his or her insurance information, or when the patient presents the wrong insurance information or phone numbers. These types of denials can also be caused by staff issues. If admitting/registration staff members do not follow admission policies and procedures, these types of denials are more likely to happen. It’s difficult to ensure that procedures are in place if there is an admitting/registration staff shortage and a high turnover rate. Another underlying cause of technical denials is when an outpatient department (e.g., radiology or IV therapy) does not get proper authorization from the payer for nonemergency procedures.

Clinical denials. These denials can often be prevented by case management intervention and they typically relate to medical necessity. Unnecessary admissions, patient dissatisfaction, and insufficient utilization review can be causes of this type of denial. Additionally, prolonged unnecessary stays caused by families or patients unable to make care decisions and placement issues for skilled nursing facilities or rehab centers are also causes.

Check out the October 2008 issue of Case Management Monthly to get the full story, and discover all the benefits of being a Case Management Monthly subscriber!

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