EDITS AND DENIALS MANAGEMENT SERVICES

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Denials


Denied! After all the hard work in setting up and following through on processes, the invoice is submitted, yet a denial is received. There are many different types of denials for both hospital claims and for professional fee claims.

 

The types of denials Excite can support are numerous:

  • DRG denial
  • Charge denial
  • Duplicate claims
  • Expired time limit
  • Coding denial
  • Line item denial
  • Medical Necessity
  • Missing information
  • Clinical denial
  • Pre-authorization denial
  • Noncovered charges
  • Concurrent Care Denials

All denials should be trended for what payers are targeting and the reason for the denials to determine the next step and initiate changes to avoid continued and repeated denials.

Medical Necessity


When talking about medical necessity, it could be either a question of the patient’s clinical picture supporting medical necessity for inpatient admission or a needed diagnosis to support a service or supply.

The patient’s clinical picture at the time of admission has to support the need for inpatient care versus outpatient care.

There has to be a diagnosis assigned that explains and supports the need for tests, services, and supplies utilized during the patient’s encounter.

Facilities should monitor and trend medical necessity denials and the reason for this type of denial. Additional education on documentation may be necessary for the provider or coding education on coding to the highest degree of specificity may be warranted.

CODING AND BILLED EDITS


Just like denials, there are also many different types of edits that we see in the healthcare industry. Some edits occur while the coder is coding in an encoder and some edits are triggered after the account is coded and completed.

 

Examples of coding and billing edits Excite can support are numerous:

  • National Correct Coding Initiative (NCCI) Edits
  • Diagnosis too generic edit
  • Payer specific edits
  • Medically Unlikely Edit (MUE)
  • Facility specific edits
  • Global surgery edit
  • Outpatient Code Editor (OCE)
  • Modifier edits

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With the constantly changing billing regulations and payer guidelines, many hospitals and physician practices lack the staff to manage denials, edits, and medical necessity reviews effectively. Utilizing the expert services of Excite Health Partners to supplement or manage your denial, edit and medical necessity review needs can be a sustainable alternative to support your revenue cycle needs. We can assist you with reducing your backlog and identify the trends to support your revenue cycle team and education needs for providers and coders.

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