The Path to Payment: Best Practices for Clinical Denials Management

Course overview

Medical necessity denials have increased as managed care has taken a large share of the Medicare and Medicaid marketplace. To address the trend, this organization created a clinical denial and appeals program for inpatient hospital admissions, which begins as early as when the patient is hospitalized and continues after an inpatient claim is denied. The Clinical Denial and Appeals (CDA) department, working collaboratively with the Utilization Management and Review department, improved their program by appealing denials within two weeks from the time of referral. Through specialization of clinical staff, expansion of the scope of the clinical appeal, and the assistance of outside resources, CDA realized gains including over 10% improvement with precertification-related denials.