Case Management

Mentor moment: Denial management

Case Management Weekly, August 29, 2012

You can’t manage what you can’t measure. 

If your hospital takes an apathetic approach to denial management, denials are likely to increase to the extent that they substantially affect the organization. Proactively distinguishing appropriate denials from those that can be successfully appealed will allow you to more accurately evaluate denials by type, physician, and point of entry into the hospital. 

Submit appeals in a timely manner and when, in the hospital’s opinion, CMS’ published instructions support the appropriateness of the admission. 

When the hospital agrees that a denial is appropriate and finds that a pattern of particular errors exists, the denials management team and other key stakeholders can identify process errors and implement improvement strategies. By continually tracking denials, the team can measure the effectiveness of improvement strategies and make necessary changes. 

Editor’s note: This article is adapted from Observation Services: A Guide to Compliant Level of Care Determinations, Third Edition published by HCPro, Inc.


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