As discussed in our previous article, it is critical to understand what is causing the increase in clinical denials. However, even with robust prevention strategies, clinical denials will still occur. The key to success lies in crafting strong appeals that tell a compelling story, backed by evidence and aligned with payer criteria.
The Importance of Robust Documentation
Effective documentation is the foundation of any successful appeal. To make your case, ensure your records include:
- Why outpatient management is not appropriate: Explain why the patient requires inpatient care, such as frequent vital sign monitoring or round-the-clock nursing care.
- Risk of adverse outcomes: Highlight the risks if the patient does not receive inpatient care, including potential decompensation or complications.
- Failed lower-level interventions: Document any outpatient, emergency department, or observation interventions that were unsuccessful.
- Complexity of comorbid conditions: Provide a detailed history of the patient’s comorbidities, which increase their risk of complications.
Structured Appeal Techniques
When denials occur, a structured, evidence-based appeal can make the difference between lost revenue and successful recovery. Follow this practical framework for building a well-organized, strong appeal:
- Introduction: Clearly state the denial reason and request reconsideration.
- Background: Summarize the patient’s clinical presentation and hospital course by writing the narrative as a clear, concise story that outlines the patient’s clinical journey and why inpatient care was necessary.
- Rebuttal: Cite objective evidence, use guidelines such as Interqual and/or MCG, provide specific documentation supporting medical necessity, and reference clinical articles to substantiate your case. Review payer policies to match payer language and ensure your appeal aligns with the payer’s criteria and uses their specific terminology as appropriate to the case.
- Request and conclusion: Restate the appeal concisely and affirm the criteria met.
- Supporting documentation: Attach the denial letter and all relevant records.
Leveraging Data to Improve Outcomes
Tracking and analyzing denial data is essential for identifying patterns, refining strategies, and improving workflows.
Key metrics to monitor include:
- Percentage of denials by payer: Identify which payers are causing the most issues and customize workflows to address their specific requirements.
- Denials by diagnosis: Focus on frequently denied diagnoses, such as sepsis and pneumonia, and collaborate with stakeholders to improve documentation and clinical criteria.
- Appeal outcomes: Evaluate success rates at the first and second levels of appeal to refine your strategies for borderline cases.
Denial prevention and appeal management are not siloed functions. Successful healthcare organizations foster collaboration among utilization review (UR), physician advisors, case management, clinical documentation integrity (CDI), and revenue cycle teams. The goal is not simply overturning individual denials, but building a sustainable, data-driven process that reduces vulnerability across the board.
Discover how to craft winning appeals and leverage real-world examples to strengthen your strategies. For actionable insights, watch the on-demand webinar, Make Your Case and Win: Strategies for Reducing Clinical Denials and Increasing Appeal Success.
