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Tip: Use physicians to prevent and appeal denials

Patient Financial Services Weekly Advisor, July 22, 2005

There are several ways physicians can help your denial management program.

For example, Christopher Snyder, DO, director of utilization and chief medical information officer, Peninsula Regional Health System in Salisbury, MD, is involved in almost every aspect of the system's denial management. He does chart review for concurrent and retrospective appeals, and he interacts with plans' medical directors. "An organization is more likely to have a fruitful discussion with a plan about an appeal if there's physician-to-physician contact," says Linda M. Fotheringill, Esq. of Fotheringill & Wade in Baltimore.

Here are some specifics on what physicians can do:

1. Audit to see if documentation is appropriate. A physician can audit her colleagues' medical records to see if they're appropriate and make suggestions for better documentation. "Documentation is crucial to preventing and combating denials," says Snyder, who audits colleagues' records for his health system. "Sometimes, if documentation is inadequate, we don't bother to appeal," he adds.

2. Educate physicians on avoiding denials. It's crucial to teach physicians what they can do to avoid denials. The auditing process is part of an overall effort by Snyder and his health system to educate physicians about denial management. After the first year of its education initiative, the system had an 80 percent reduction in its denial rate for claims related to stroke. "Physicians listen better to other physicians," says Linda Peeno, a Kentucky consultant and former executive with both the insurance and healthcare industries. "They need to be taught what's important for purposes of getting paid, and why more medical information is better than less," she says.

3. Negotiate contracts. You also can use physicians to negotiate contracts with plans. Snyder does this as part of his job. "Physicians are in a unique position to negotiate on behalf of their organization and understand the clinical issues," says Tammy Tipton, president of Appeal Solutions in Blanchard, OK.

"Also, they can interpret aggregate denial data from their hospital, medical group or provider organization and use this information to target concessions they want in their contracts," she says.

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