Health Information Management

Decisions, decisions, decisions: Appealing denials, addressing interest, and making a case

HIM Connection, August 23, 2011

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Denied claims got you down? An upper-level appeal may be the answer.

Of course, organizations must make thoughtful decisions, on a case-by-case basis, when it comes to appealing claim denials.
 
Giving claim denials individualized attention allows the hospital to learn something even if it decides not to appeal, says Michael Taylor, MD, vice president of clinical operations at Executive Health Resources (EHR) in Newtown Square, PA. "If they conclude the denial is appropriate, they should correct their processes so that the mistake does not happen again."
 
However, most providers choose to appeal at one point or another, and a host of decisions influence that choice. You need a strong RAC team leader to make these decisions, but that leader absolutely must have access to a multidisciplinary team. Without help, the RAC team leader will struggle to effectively appeal and meet the tight time frame necessary to prevent recoupment, says Taylor.
 
You may want to involve compliance staff members, legal counsel, members of the financial team, HIM staff, and a physician to help determine the appropriateness of an appeal. Considering the number of HIM directors and managers who lead and participate in RAC teams, understanding the appeals process and the decisions involved is paramount.
 
Click here to read more in the August issue of Medical Records Briefing.



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