Tag: medical necessity denials

Prior Authorization Changes

United Healthcare Prior Authorization Changes: Impact on Denials

UnitedHealthcare’s (UHC’s) plan to remove prior authorization requirements affecting roughly 1,700 procedure codes across its health plan products deserves a careful welcome. The UnitedHealthcare prior authorization changes could mean fewer approval steps and earlier access to needed services for patients. For healthcare organizations, the change could reduce administrative work and prevent some authorization-related denials. From […]
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Status Integrity in Hospitals

Status Integrity in Hospitals: What CDI and UR Teams Need to Know

Hospitals have spent years addressing medical necessity denials after claims are submitted. Traditionally, this has involved writing appeals, completing peer-to-peer reviews, discussing payer trends, and reviewing denial dashboards. However, the next level of denial prevention will not be achieved through the appeal process alone. Instead, it must start much earlier—at the point where patient status, […]
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A Rebeginner Guide to Peer-to-Peer Appeals

A Rebeginner’s Guide to Peer-to-Peer Appeals

Peer-to-peer (P2P) appeals can be challenging, particularly when a denial is based on medical necessity, level of care, insufficient documentation, or payer-specific criteria. However, each appeal is also an opportunity to better understand the clinical record, identify documentation gaps, and improve future denial prevention efforts. You may be wondering why a guide like this is […]
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Denial management in 2025

Denial Management in 2025: Proactive Strategies to Reduce Claim Denials

Denials have always been a challenge for healthcare providers, but denial management in 2025 they’ve reached unprecedented levels of financial and operational impact. Studies show that denial rates now average 11.8% of all claims, with some providers reporting initial denial rates as high as 20%. For revenue cycle management (RCM) leaders, this isn’t just a […]
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Denials Management Versus Denials Avoidance_ CDI Can Capitalize

Clinical Documentation Integrity: A Proactive Approach to Denials Prevention

The COVID-19 pandemic placed significant financial pressure on hospitals. Hospitals faced higher costs for treating patients with severe illness and longer stays. At the same time, many postponed profitable elective procedures, including joint replacements and same-day surgeries. A study published in the Annals of Surgery estimated that stopping major elective surgeries during the pandemic cost […]
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