Corporate Compliance

Identifying unfair claims denials

Healthcare Auditing Weekly, February 22, 2005

Last week we learned about some of the reasons why claims are denied. However, there are some denials that are unfair. If you think some of your organization's claims should not have been denied, follow these steps to confirm it:

  • Obtain the facility's report that includes the payment amounts expected based on the managed-care contract. Consider modifying this report to focus only in those with denial codes or payment variances. Review variances against the contract to determine denial trends.

  • Compare this report to the payments received.

  • If the facility does not have the above report, develop an ad hoc report of patients with specific payers. Note those items and services that are payable at various rates by the contract.

  • Review each account against the contract to determine whether the denials are appropriate.

  • Review the facility's contract management system. Determine whether the system includes payer-specific contract terms and reimbursement rates for services the facility renders.

    The above tip is an excerpt from the book "Hospital Auditing and Monitoring: Sample Programs for Key Risk Areas." Copyright 2004 by HCPro, Inc. This book is a step-by-step, practical manual that offers sample audit programs for the most troublesome areas that a hospital must audit. The binder and CD-ROM are filled with actual audit programs used by auditors and compliance officers in the field. Click here for more information or to order your copy today.

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