• E-mail
• Print
• RSS

Appealing a denial

Compliance Monitor, February 15, 2006

Want to receive articles like this one in your inbox? Subscribe to Compliance Monitor!

Knowing when and when not to appeal is the first step in the denials-management process. Following are two cases in which an appeal is appropriate:

1. No procedure precertification. For example, a radiologist has a precertification for an abdominal CT and orders a second CT of the chest after finding an abnormality in the patient's abdomen, but the payer denies the second, nonprecertified CT scan. "It [is] better for the patient and cheaper for the payer to have both procedures done while the patient [is] still in the scanner," Terri Rinker, MHA, reimbursement manager for Community Hospital Anderson (IN) says.

2. Lack of medical necessity. For example, an ED patient with chronic pain usually treated by his or her primary physician experiences a sharp increase in pain, spike in temperature, or other condition. It's the middle of the night or the weekend and the patient's PCP's office is closed, so he or she goes to the ED. The payer denies the claim.

A close review of the patient's medical record can help determine whether appealing a denied claim in this instance is appropriate. Either health information management or your claims denial team should inform nurses about the importance of noting in the medical record why the patient decided to come to the ED.

This tip is an excerpt from Strategies for Health Care Compliance.

Editor's note: If you have a tip that you would like to share with your compliance peers, please send it to Compliance Monitor Editor Kelly Bilodeau and we'll publish it in a future issue of Compliance Monitor.

Want to receive articles like this one in your inbox? Subscribe to Compliance Monitor!

• E-mail to a Colleague
• Print
• RSS
• Archive