New to Denials

BeckyA

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!

mitchellan

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.

psweston

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?

mitchellan

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! 

kdrenzek

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?

kshumpert

BeckyA said:

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!

Are you working clinical validation, coding or medical necessity appeals? 

kshumpert

kdrenzek said:

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?

I am answering this based on previous experience in another facility.  We had a template letter that went out the provider informing them of the denial.  I can't remember all the information that was in the letter, but it contained contact information.  The letter would go to the provider with the problematic documentation on record.  So, a letter could go to the attending, pulmonologist and ID if they all had problematic documentation.  Of course, this took additional time on our part to track it.  We did this to try to curb some of the bad documentation that we were getting in the medical record.  A copy of the letter went in their quality file.  It was not captured in peer review statistics though.  Since a copy was going in their file, they always called.  They were irritated the first few times, but it also opened the opportunity to get them involved in the appeal process so that they could see the issue first hand

nzd1980

nayloram said:

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.

Helpful Angelica