Tag: Medical Necessity

Modifier 25

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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Pushing Back Against Medicare Advantage SNF Denials

Pushing Back Against Medicare Advantage SNF Denials: Part 1

Despite ongoing concerns about denials and beneficiary access to care, Medicare Advantage (MA) companies remain in the spotlight as their market penetration continues to grow. In April 2022, a report from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) highlighted a significant issue in the capitated payment model employed […]
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Denial Management Services

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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Clinical Denials

Clinical Denials: Prevention Is The Best Medicine

Clinical denials are a fact of life for hospitals. Providers must contend with a number of government audits conducted by several different organizations. On the private payer side, hospitals must comply with complex approval processes related to prior authorizations, admission status and medical necessity. At Becker’s Hospital Review’s 10th Annual Meeting in Chicago, R1 RCM hosted a […]
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Medical Coding, Medical Billing, Denial Management, RCM

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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Eliminate Claim Denials For Medical Necessity

There are numerous reasons for claims denials but most of them come down to some form of documentation error, according to Karen Meador, MD, MBA, Senior Physician Executive and Managing Director at the BDO Center for Healthcare Excellence in New York, NY. Furthermore, most of the claims she has seen that “rise to the level […]
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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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