22. January 2015 14:21
Help your hospital get out of denial by addressing the top five reasons for claim denials.
When the causal reasons are understood, most denials are both preventable and appealable.
The top five reasons given for claim denials are:
- Inpatient versus Outpatient assignment
- Authorization issues such as day/s not considered medically necessary, or untimely clinical update
- No admission order
- 2–Midnights rule
- Medical necessity not met
Read more about each of the top five reasons for denials and how to address issues before they occur in a claim, in the following online article on utilization management: http://www.craneware.com/resources/white-papers/rac-utilization-management
Do you have an interesting denial story to share? We’d love to hear from you.
19. January 2015 15:37
Forget resolutions about writing your memoirs, climbing Mt. Everest, or seeing the West while learning to play guitar (actually did that for a month, but that’s another story, for another time), 2015 is the year to be real. We’re fortunate to work in a healthcare environment that is constantly changing, keeping us sharp and challenging us to learn new approaches and test our skills. Never a dull moment.
What can we accomplish this year?
- Better data for reimbursement and improving quality outcomes - Learn the latest on savvy data management and the reimbursement rules that are quite different in 2015.
- Healthcare for more people at high quality - Help attract market share for your organization by doing your part to ensure accurate charging, competitive pricing, and satisfied patients.
- Put your best foot forward - Patients face higher out-of-pocket costs and now are searching online to compare prices for common procedures. As this information is now available to the public from both CMS and commercial sources, be sure your organization’s data presents well.
- Get earned payments and keep them - Focal points of operational efficiency, compliance, and correctly documenting earned reimbursement – these are the components of the revenue integrity approach that is effective in preventing audit take-backs and compliance penalties, while advancing financial performance.
- Make connections and strengthen margin - Today there are means to see what is spent on supply purchases and providing care, and then to compare these expenses with reimbursement. No one can afford to skip connecting and reviewing this information in 2015. It is key to negotiations with payors and suppliers, as well as to future reimbursement.
Just because 2015 is the year to focus on revenue integrity doesn’t mean you can’t still learn another language and foster better relationships by phoning and e-mailing more often. You can do those things in 2015 to create a more rewarding year on the job in many ways.
What are your thoughts about advancing in the year ahead? Your contributions to this community are appreciated.
"We cannot walk alone. And as we walk, we must make the pledge that we shall always march ahead. We cannot turn back." (Source: Martin Luther King, Jr. "I Have a Dream" speech)
16. January 2015 15:18
Hospitals are facing increased scrutiny on pricing, and a new tool in use by Blue Cross Blue Shield of North Carolina is described in Forbes Jan. 15, 2015 article, “Could This Pricing Tool For Consumers Disrupt Healthcare?” The new tool lets consumers compare pricing across in-network organizations for common procedures, which could be a game-changer if similar tools spring up around the country. At least one provider has already modified its pricing to be more competitive within the tool the article reports.
Transparent, competitive pricing is increasingly important as consumers carry more of the burden to pay with high-deductible plans. Craneware’s Brian Workinger authored an article about pricing strategy mentioned on the cover of this month’s Executive Insight magazine.
Providers must evaluate their pricing on an on-going basis to continue to thrive in the evolving market.
The Advance Healthcare, Executive Insight article, “Revenue Cycle and Pricing Transparency,” details a dozen insights into setting market-competitive pricing and generating a reasonable margin.
Specifically, the article explains four key components to setting effective pricing, which include factoring in financial goals, market competition, payment and reimbursement models, and the cost to provide care. In addition to considering these factors,
The article, “Revenue Cycle and Pricing Transparency,” can be read on pages 33-34 of the e-magazine here.
What are your thoughts and feelings about this latest development? How is your organization prepared to meet the evolving pressures of consumerism in healthcare?