Revenue Cycle

Tip: 5 principles of denial prevention

Patient Financial Services Weekly Advisor, July 9, 2004

All successful communication in the medical necessity certification process relies on five key tenets, according to Simon D. Rosenstein, MD, MBA, founder of Rosenstein Health Consulting, LLC. Each plays a part in creating a clear, understandable, and influential communication of your patient's medical necessity for acute care.

1. Making the case

  • Acute care: What is the most intensive, acute service the patient is receiving?
  • Stability issues: What clinical factors would make discharge now unsafe?
  • Risks of testing: What life-threatening complications are possible?
  • Risks of treatment: What life-threatening complications are possible?

    2. Presenting the status

  • Is the admission or the continued stay at acute level in question?
  • Is the intensity of service in question?
  • Has the day been denied? Or pended?
  • Is it time to set up the expedited appeal?

    3. Know the payer

  • To which ORG or ISD subset is the payer mapping this patient's case?
  • What extensions, deviations, or disqualifications from the guideline are apparent?
  • Know and anticipate the payer's past behavior and patterns of denial

    4. Know your hospital

  • Be aware of your hospital's previous denial pattern and known hospital issues
  • Know the acknowledged strengths and expertise of your hospital
  • Use the well-known physicians and centers of excellence within your system.

    5. Know the law

  • Track timelines/deadlines and response times
  • Determine the clinical "exigencies" of this case
  • Would this case be eventually appealable externally?

    Next week: Rosenstein's tips on writing an effective appeal letter.

    For more information on claims denials, click here to view Rosenstein's book, Appealing and Preventing Denied Claims, copyright 2004 by HCPro Inc.

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