Clinical denials due to errors in medical necessity documentation, length of stay, and level of care may be a fact of life for healthcare providers, but there are procedures that can be put in place to reduce the denial of payments by payers. To achieve payment, resolution of clinical denials requires an appeal on the part of the healthcare organization. In this Guidehouse On Healthcare episode, Guidehouse Senior Vice President Shela Schemel discusses the benefits of using an integrated and holistic solution for inpatient and outpatient units. Schemel highlights the effectiveness of the appeal process in collaboration with a healthcare provider’s utilization management department, patient access services, revenue integrity, patient financial services, and health information management.
She emphasizes that the professional denials team should include nurses who provide clinical education with a focus on case management, utilization management, medical review, coding, and claims processes. Additionally, team members should have payer experience. When everyone on the team understands the payer side of it, healthcare providers can rely on this experienced team to have a superior knowledge of evidence-based clinical guidelines, applicable state and federal agency regulatory mandates, coding guidelines, and of changing policies. Denial management can be accomplished with critical evaluation and decision-making about whether an appeal is warranted.