Tag: Medical Necessity

Medical Coding Denials

Top 10 Medical Coding Denials and How to Avoid Them

Medical coding denials are a significant challenge for healthcare providers, revenue cycle managers, and billing departments. Not only do they disrupt the cash flow of healthcare organizations, but they also result in increased administrative costs and delayed patient care reimbursements. According to industry data, nearly 9% of claims are initially denied, and a substantial portion […]
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healthcare compliance issue Logs

Healthcare Compliance Issue Logs & Risk Assessment

Troubleshooting and insurance: These are the dual purposes of maintaining a detailed Healthcare Compliance Issue Logs, according to a senior compliance executive. Speaking at AAPC’s HEALTHCON Regional, the senior compliance executive highlighted the Office of Inspector General’s (OIG) new voluntary compliance guidance, emphasizing its importance even for organizations already familiar with the seven elements of […]
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Prior Authorizations

Prior Authorization in Medicare: What You Need to Know

Prior authorization, the requirement for pre-approval from your insurer for certain services, is a common practice in both Original Medicare and Medicare Advantage (MA) plans. While it helps manage utilization and costs, it can also be frustrating, especially when a request is denied. A 2023 study by health policy research revealed the increasing prevalence of […]
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medical necessity documentation

Medical Necessity Documentation: A Guide to Reducing Claim Denials

Claim denials are a significant headache for healthcare providers, impacting revenue and administrative efficiency. While denials can stem from various issues, a large majority are rooted in documentation errors, particularly those related to demonstrating medical necessity. Defining Medical Necessity: The American Medical Association (AMA) defines medical necessity as healthcare services or products provided to a […]
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Understanding Modifier 25: A Comprehensive Guide

Understanding Modifier 25: A Comprehensive Guide

Often, a seemingly routine preventive visit or minor surgery can take an unexpected turn when a patient mentions a new concern, such as “Oh, by the way…” If a physician provides additional care beyond the originally scheduled service, you may be able to bill for a separate evaluation and management (E/M) service using modifier 25. […]
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Medical Necessity and Denial Management

Medical Necessity and Denial Management

Quality work reduces the burden of the denial management process. When my children were young, they really enjoyed the movie “The Neverending Story.” It’s about a boy who reads a magical book that tells a story of a young warrior whose task is to stop a dark force called “The Nothing” from engulfing a mystical […]
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How Analytics Can Help Boost the Success of EHR

How Analytics Can Help Boost the Success of EHR Go-Lives

At HIMSS19, John Rekart, chief of quality management and informatics at the California Department of Corrections and Rehabilitation will show how homegrown analytics enabled a 25 percent post-implementation reduction in sentinel events. New electronic health record rollouts are infamously fraught with risk. At best, a they can cause workflow disruption, confusion among clinical staff and […]
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Fight Back Against Denied Insurance Claims

Fight Back Against Denied Insurance Claims: 5 Steps

Appealing a denied insurance claim can be frustrating, but don’t give up! By following these steps and understanding the process, you can increase your chances of getting the coverage you deserve. Here’s a detailed guide: 1. Understand Why Your Claim Was Denied (and Know Your Rights) Review the Denial Letter Carefully: This document should clearly […]
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