Agenda
          Denials
          Commonly Used Terminology
          What We See and Why
          Root Causes
          Denials Management and Prevention
          How CDI Plays a Vital Role
          The Comprehensive Solution
          Current Payor Trends
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      What is a Denial?
      Anything at risk for write of
       You expected to get paid for it and you didn’t
       Typically categorized into 2 groups
            − Clinical: does not appear to meet medical necessity, no 
              authorization, LCD/NCD, DRG Downgrade
            − Technical: administrative in nature (timely filing)
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       Definitions
        Remit
          − Notice of and explanation of reasons for payment, adjustment, denial, and/or non 
            covered charges of a medical claim
        835
          − Electronic remit from payor through claims submission system
          − 837 is the actual submission from the provider to the payor
        ANSI Code
          − American National Standards Institute
          − Standardized claim adjustment reason codes (whatever)
        EOB
          − Explanation of benefits
        Denial Code
          − ANSI code present on remit
        Contractual
          − Negotiated discount between payor and provider
        Expected
          − “Net” is expected payment after discount applied
          − “Gross” is total charges with no discount yet applied
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      Gross vs. Net
      Example: Total charges of $10,000 with a negotiated payor discount 
      of 75%
        GROSS                                  NET
        $10,000 Total Charges                  $10,000 Total Charges
        $0 Discount Applied                    $7,500 Negotiated 
        $10,000 Account                        Discount
        Balance                                $2,500 Account Balance
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      Who Denies These Claims?
       Medicare hires contractors referred to as MACs who are 
         fiscal intermediaries who make payments on behalf of 
         Medicare.
       RACs are contractors hired by Medicare to audit and collect 
         overpayments to hospitals.
       QIO’s- Quality Improvement Organizations
       For commercial, generally someone with advanced medical 
         training will review these claims (i.e. Medical director, 
         nurses with advanced training).
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