Approaching and dealing with commercial payers is "very much a game," but by understanding current trends in denials and learning the best practices for documenting and demonstrating medical necessity, managed care organizations can substantially reduce denials for inpatient care, according to Ralph Wuebker, vice president of Audit, Compliance and Education for Executive Health Resources.
During a breakout session on Monday at the ANI: 2012 HFMA National Institute conference in Las Vegas, Wuebker and Stacie Tucker, corporate director of care management at Jewish Hospital and St. Mary's Healthcare in Louisville, Ky., discussed how denials can be reduced by implementing a consistent utilization management process across all payer types and patient populations.
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"Unfortunately, it's very much a game of push and pull," said Wuebker during his presentation. "It's easier for [payers] to deny a case than to approve a case. When it comes down to it, you need to appeal as much as you possibly can and when the denial is inappropriate, appeal as often as possible."
Wuebker mentioned that many hospitals have been trained to self-deny patient cases that may meet medical necessity criteria due to commercial payers aggressively denying cases over time.
"These are cases that could have qualified for inpatient but failed first level inpatient screening or observation cases that could have qualified for inpatient care," he said. "Most folks don't realize what a problem self-denials are."
Wuebker said there are a number of keys to success for healthcare organizations when it comes to reducing denials.
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"Number one, first and foremost – if you can appeal these cases while the patient is still in the hospital, that is your best chance," he said. "The most effective way is not to write a letter. Make a phone call because the case is much more likely to get overturned that way."
He also mentioned never lying or stretching the truth when it comes to these cases, and to always hold the payer accountable for their decisions.
"You always have a right to concurrent review and reconsideration, even when the hospital is notified of the denial after the patient has been discharged," he said. "And think in ink. Documentation of everything is key."
Tucker mentioned the changes her organization has undergone in order to reduce denials.
"We took the control back from the commercial payers. We have daily monitoring by management staff of all commercial cases over 23 hours and our utilization review staff took ownership of their cases – they knew the intent of all their cases," she said. "We also take the denials of those cases if everyone involved believes that the inpatient care was appropriate. In 2011, our medical necessity denials compared to patient days was .3 percent. Our goal for the year was 1 percent."