by Dawn Crump, Senior Director, Revenue Cycle and Denial Management Solutions, Intersect Healthcare
Reproduced with permission of RCM Answers
Its been 10 years since the Recovery Audit Contractors rocked hospital providers world with a record number of audits and overpayment determinations. Commercial health plans took notice and refined the art of audits and denials, creating even more administrative burdens and financial liabilities for hospitals and patients to shoulder. 2019 will be no different, commercial health plans will continue to deny short stays, experimental procedures, high cost drugs and common costly procedures for lack of medical necessity. There will be even more growth in clinical diagnosis validation denials which are not only costly but time consuming to appeal. More and more hospitals will escalate their payment disputes and look for settlements to alleviate some of the burden brought on by heavy denials. Hospitals need to work together within their internal departments to fix true denials and externally with their peers to identify egregious behavior and look for wins to stop the abuse from payers.