Providers must learn to pick their battles in pushing back against questionable recoveries.
Denials pit insurers against hospitals. Despite costly attention, improved clinical documentation remains elusive. Insurers retain premium dollars for their stockholders – not their customers, our patients. They save by downgrading severe diagnoses (MCCs) or removing moderate co-morbidities (CCs). Our appeals preserve hospital revenue in real dollars.
Ridiculous denials are frustrating. Vent, and then, respond. Are you arguing over the Titanic’s deck chairs? Insurers may correctly identify unsubstantiated diagnoses. If legitimate, return the money. If the DRG or reimbursement doesn’t materially change, where’s the value? Fight the fight worth fighting.
Review their denial points. What typical issues are not mentioned? Insurers perform cursory reviews, often overlooking information and diagnoses that aren’t highlighted in the discharge summary. Your overloaded providers short-change the discharge summaries and don’t update the problem list. A bad mix!
Look for internally consistent documentation, including the physical examination. Be a detective. The best information may lie in the EMS run sheet, nursing notes, ED labs, and ancillary data. Verify that active diagnoses are documented, evaluated, and treated. Chronic diagnoses must be clinically relevant. Document lab values, tests, procedures, and vitals that substantiate the patient’s disease severity or provisional diagnoses. Issues may arise mid-admission and not make it to the problem list. Tell the story.
Insurers can’t debate validated national scoring systems (pneumonia, PSI score; malnutrition, ASPEN score (BMI/labs irrelevant); encephalopathy, Glasgow; renal, AKIN, RIFLE; sepsis, q SOFA, SIRS, NEWS, MEWS; heart failure, MAGGIC, NYHA, GWTG; liver failure, MELD, Maddrey). Define systemic effects or risk change.
Physician advisors (PAs) should provide UR nurses standard national references for first-level appeals to fight outdated or misapplied insurers’ literature. Use consultants’ notes if supportive. We may use more current literature. I refute their points sequentially, summarize the denial’s inaccuracies, confirm our applied DRG, and request an identifiable subspecialty reviewer. While inclusive, it is intended for higher-level appeal reading.
Enticed by lucrative promises, contracted hospitals don’t expect obstacles to billing. Regretfully, they ceded power by allowing unilateral contract changes and limits of two appeals to the insurer. Appealing outside of restrictive contract provisions remains cost-prohibitive. Hospitals need to navigate the restrictions to advocate for their patients (and state laws protecting patients). Any such moves also have to survive in the court of public opinion, where media biases can arise. By representing the patient, the hospital gains lower-cost access to both arbitration and the Administrative Law Judge (ALJ). Otherwise, beyond complaining to CMS, hospitals must accept unsubstantiated denials. If lost income becomes a real target, hospitals may address future contract options. If uncontracted, use all of your appeal levels!
It is hard to not get emotionally involved in ridiculous denials, and fight everything. We are better PAs when, in the moment, we become Don Quixote and fight windmills. Track typical denial points and educate staff to close the gaps. The best way to win appeals remains preventing them, initially. We need to argue to participate in contracting, as a poorly written contract handcuffs our ability to protect the hospital – and, ultimately, our patients.
Programming Note: Listen to Dr. Markiewitz on Monitor Mondays, Monday, March 29 at 10 a.m. Eastern as he reports this story live.
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Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
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