May

27

Case management’s role in managing denials

By Case Management Weekly

With the economy in a downturn, most people are focusing on cost-saving efforts, and that goes for providers and payers alike. This is why a comprehensive understanding of hospital denials and their root causes will not only avoid front-end denials, but will also bring in revenue that may have gone unrecognized or been determined unrecoupable.

To effectively avert and overturn denials, it is imperative that case managers have a firm understanding of payer methodologies. Payer methodologies in reimbursements and denials can vary considerably, but case managers should have a clear comprehension of a payer’s expectations up front so they can build a strong case for medical necessity based on payer expectations.

To understand denials management, case managers should first understand basic individual payer utilization review (UR) rules and contract management. The best way to do this is to review UR payer and provider contracts, which are easily obtained from payers and providers. Case managers should review these to build an understanding of payer rules regarding status, billing, denials, and appeals.

Check out the May 2009 issue of Case Management Monthly to read the full article.