By Aaron Drummond, CCS (Denials specialist at Medical Audit Resource Services (MARSI)
Insurance denials can severely affect a facility’s revenue cycle. A successful appeal often requires a concerted effort between clinical and coding professionals, who often speak different languages in terms of interpreting documentation and applying guidelines.
Payers often have their own way of looking at things, which frequently differs from the facility’s viewpoint. To the facility, the importance of quickly identifying severe conditions such as sepsis or organ failure and initiating appropriate care is paramount. To the payer, having the luxury of looking at the case after the fact, there is often an expectation that every patient presentation should be a textbook one, in which the patient clearly had the condition for which they were treated. This includes meeting the expected diagnostic criteria and receiving the expected treatment without any other possible clinical scenario. Continue Reading Full Article
This article was published on March 6, 2023 in The Journal of AHIMA, which is the official publication of the American Health Information Management Association
