This judicial term, the Supreme Court of the United States (SCOTUS) has agreed to hear two joint cases regarding the standard of scienter (“intent or knowledge of wrongdoing”) in legal situations pertaining to the False Claims Act (FCA).
Requiring Medicare Advantage (MA) organizations (MAO) to definitively identify payment denials on encounter records submitted for MA would enhance program oversight and help combat fraud, according to a new report submitted by the Office of Inspector General (OIG). Although most 2019 MA...Read More »
I first became aware of clinical validation denials 12 years ago. I had the great fortune of working alongside a very astute coder at the time. When the Medicare Recovery Audit Contractors began audits for clinical validation in 2011, she quickly...Read More »
FEATURES 6 Appeal writing 101 11 CDI-related denials, tracking, and tools for appeal 17 Case study: Medical necessity denials management 25 ...Read More »
While Dorothy worried about lions, tigers, and bears (oh my!), CDI professionals involved in the denials management process develop a sixth sense around certain diagnoses known to be at high risk of denial. While some courage, brains, and heart will get you...Read More »
Nowhere does work in the healthcare setting feel more like a courtroom than the denials arena. Hospitals and healthcare systems seek to provide the best quality of care to their patients, but that care can come grinding to a halt if an organization’s billing gets...Read More »
The process of denials and appeals is often referred to as a form of "word game" with players crafting persuasive arguments using specific language to present and counter claims. It’s important to recognize, however, that the stakes are
