Tag: Appeals

Medicare Advantage Insurers

Senators seek accountability from Medicare Advantage insurers on claims denials

In Congress this week, it wasn’t just pharmacy benefit managers facing scrutiny. The Senate’s Permanent Subcommittee on Investigations directed its attention towards Medicare Advantage (MA) plans, seeking explanations for claims denials. During the hearing, the committee’s chairman highlighted that letters were sent to the three largest MA plans—UnitedHealthcare, Humana, and Aetna—requesting documentation regarding their decision-making […]
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Pelvic Abscess Denials

Physician CDI Input and Clinical Validation for Pelvic Abscess Denial

Case study proves the need for physicians to be members of the CDI team. Having a strong denials management team is critical for facilities. If providers do not leverage proper resources to generate strong appeal letters, the third-party payers will uphold their decisions to remove or change diagnosis or procedure codes. This usually will lead […]
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“Defensive” Undercoding Is Indefensible

  Undercoding, or reporting a lesser service than was performed and documented, is sometimes employed as a defensive strategy to stave off claims denials or audits. But, undercoding can make a provider an outlier, and may create consequential patient care, compliance, and financial liabilities. For example: Undercoding Leaves Money On The Table, Driving Down Provider […]
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