Ask The Appeal Experts
Submit your questions for expert advice on your denial and appeal management concerns. We will share with the community relevant, thought-provoking, and difficult questions answered by our panel of experts.
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Q:Our facility is beginning to see a trend where a claim is being denied for two different reasons. The claim is originally denied for medical necessity, we appeal the determination, and it is overturned. UHC then performs another review denying the DRG. Any suggestion or advice on how approach this? We are also seeing cases overturned for medical necessity and then a coding or clinical validation denial arrives.A:
Here are some thoughts:
- Make the CDS team aware of what is happening. Perhaps they can look to see if their intervention in any of the cases might have made a difference and use that information going forward.
- Are the clinical validation denials actually valid denials? Querying about the clinical validity of a diagnosis, though difficult to do sometimes, is an important part of the CDS’ job.
- Some hospitals have CDS’ review all discharge charts prior to billing to make sure that documentation is as strong as possible prior to billing.
- Discuss the recurring issue with UHC payer representatives and seek clarity on their criteria for both medical necessity and DRG validation. This might help you better tailor your documentation and appeals.
- Track denial patterns to identify common reasons and adjust your processes accordingly if necessary. This proactive approach might help reduce the frequency of denials and improve your overall claim approval rate.
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Q:A consulting company we worked with many years ago had us have Medicare Advantage (MA) patients sign an appointment of representative (AOR) form right from the beginning of their admission. Of course, it takes more resources to get signatures from the patient after discharge. What are the pros and cons of having the patient sign the AOR form at admission?A:
The whole point of having the MA patient assign you their rights of appeal is so that you can appeal on behalf of the patient. For Medicare Advantage plans, appealing on behalf of the patient allows you to go through the 5-level Medicare appeal process which is not available to the provider if the provider is contracted with the plan. When you appeal on behalf of the facility, you get the number of internal (back to the payer) appeal levels that are described in your payer-provider contract or in the payer’s provider manual.
Best practice is to have the AOR form signed by the patient on admission. Some hospitals have struggled with implementing the process because it involves changes in forms, or adding new forms to registration packets, and questions arise about why every patient needs to sign the form even though not every admission will be denied. MA plans may have their own AOR form they provide for use, however, the CMS AOR form 1696 should be accepted by MA plans. You can download the form here: CMS 1696.