Case Management

Sneak peek: Denial prevention via records and contract language

Case Management Weekly, June 2, 2010

Documentation by the medical staff is a pillar of reimbursement success. 

Most physicians don’t think in terms of claims denial prevention, but rather in terms of how to document clinical findings, symptoms, and signs, and what the plan of care will be. 

However, the medical record also must stand as proof to an outside agency (e.g., the Quality Improvement Organization) that the medical care provided by the physician and the facility was warranted and actually performed. 

In executing a plan to prevent denials, clinical documentation improvement specialists and case managers should work together to educate the medical staff about the need to describe the acute episode in a manner that demonstrates unequivocally that the patient can’t be treated at a lower level of care. 

Denial prevention does not exist in case management alone. Case management staff, medical staff, and executives must share it along with staff from admissions, registration, health information management, nursing, and any other department that has a hand in the business side of patient care. 

Check out the June 2010 issue of Case Management Monthly to learn more. You also can discover the benefits of becoming a Case Management Monthly subscriber

Most Popular