New to Denials

Hi all!

I am new to working on denials at my facility and am looking for some good resources to help me expand my knowledge in working on the appeals process - what works, what doesn't work, best practices, etc. Are there any good articles or webinars to explore? Any direction would be helpful. Thanks!

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Comments

  • Hi Becky!

    Intersect Healthcare (Appeal Masters) has great webinars on "Successfully Appealing..." various topics.  You can sign up for them for free, as long as you have an organizational email address (no yahoo, gmail, or Hotmail allowed).  I have successfully appealed several denials regarding noncompliance or adherence to the AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice. I recommend using a bullet point format or break down by "elements" with the elements being each point the payer denied (restating their exact language).  Refute each element with supporting clinical information and cite sources for that particular element. 

    Some providers use "narrative" format; I don't recommend that format, neither does Appeal Masters. Narrative format can easily distract or lose the reader/audience. 

    I hope this helps!

    Sincerely,

    Angelica N.

  • I am a physician with training and experience in CDI, as well as appealing denials for medical necessity and clinical validity.  Im interested in  assisting organizations with clinical validation denial appeals outside of my home institution. Any suggestions on how to go about finding opportunities for this?
  • psweston said:
    I am a physician with training and experience in CDI, as well as appealing denials for medical necessity and clinical validity.  Im interested in  assisting organizations with clinical validation denial appeals outside of my home institution. Any suggestions on how to go about finding opportunities for this?
    I recommend reaching to companies like Appeal Masters or R1 to see if they have opportunities for additional staff.  I don't think hospital organizations (at least not those I have worked for) hire external, independent staff for denials/appeals.  I have seen some contract auditors for the HIM Dept. I'm not sure if they belong to a consulting company or agency, or were independent.  I hope that helps! 
  • Hello, I am trying to start a process for educating Providers when there is a DRG denial/reassignment. I was thinking of drafting a letter that could be tailored to the specific case and providing it to the Physician, with an option to them to have a sit down with me if they had further questions. Does this seem reasonable? Does anyone else do anything like this? What are people doing?
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