While medical necessity remains the number one type of denials in 2021, our team has seen three additional causes emerge as significant sources of denials this year. If your hospital or health system is experiencing any of these denials, know that there are answers and ways to prevent them from occurring in the future.
1. Chest Pain
Chest pain remains one of the primary reasons patients visit emergency rooms; however, it is more challenging to get these claims paid if there is no evidence that the patient had suffered from a heart attack.
When working with chest pain claims, there is always risk involved. Documentation before a denial should reflect risk. If a claim is denied, the appeal letters should focus on patient risk if the tests and procedures had not been completed. The services provided to prevent or rule out a heart attack (e.g., Troponin tests, stints) are generally considered a medical necessity, so proper documentation of the services themselves and reasons for the services is pivotal for denial avoidance. This is why it is beneficial to have an open line of communication with providers and coding teams, as everyone can be on the same page regarding appropriate documentation and protocols in treatment or diagnosis plans.
2. Acute vs. Chronic
The Advent team has seen a significant rise in denials related to discrepancies on how to pay procedures for acute versus chronic medical conditions. For both acute and chronic medical conditions, there needs to be factual documentation explaining why the condition is acute or chronic. Generally, remittance is different between the two diagnoses, so the documentation needs to reflect that accurately.
Clinical expertise is an exceptional tool to use in denial management. In most cases, the doctor or RN can provide the information needed, such as a 275, in order to explain the medical necessity of specific procedures or decisions made. In other cases, it may be beneficial for the specialized practitioner to comment on patient care details.
3. Inpatient vs. Outpatient Denials
Another trend in denials for 2021 is the inpatient/outpatient dichotomy. The first step in reviewing the claim is to look at how the provider wrote the patient order – does it indicate inpatient or outpatient?
If the documentation is unclear, use your resources. Ask the RNs and doctors why a particular patient was admitted as an inpatient instead of being given an outpatient treatment plan. We find that asking the clinicians what they would have done for their own family in a similar situation often yields relevant information.
Another way to understand why a provider admitted a particular patient is by looking at the industry standard for that procedure. For instance, laparoscopic gallbladder removal is generally considered an outpatient procedure. However, when the patient needs additional medical treatment or recovery, such as increased blood loss due to anemia, the procedure can become inpatient. Complications are a common reason why some patients are considered inpatient.
Sometimes the industry norm isn’t the best option for specific patients. A clinician needs to consider the level of jeopardy the patient might be in if they return home. Social admissions are when social circumstances, instead of medical issues, are the cause of a patient being admitted. This may be a case of a patient awaiting a rehab or nursing facility.
Paying close attention to these trends is crucial in curbing your denials. Understanding the root cause of denials is the first step. Are you looking for even more information on the denial avoidance process? Check out the video below of Deborah Horne, Advent Health Partners’ VP of Operations, discussing these considerations in further detail, or get in touch with our team to discuss our denial prevention and recovery solutions.