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unwarranted denials IP or OP? from Specific payers UHC or Humana
DENIALS & APPEALS
Are other facilities being bombarded with denials from Humana and UHC and they are not warranted? We would love to hear from you.
Anecdotal evidence from a RAC user group is that you are not alone. Those two are the worst with inappropriate denials.
Yes. UHC especially. We've contracted with a vendor to do Peer-to-peer while the patient is in house, and we also have our UR team reviewing based on MCG guidelines to make determinations upfront as to whether it is appropriate for Obs or IP. If Obs, they obtain the necessary order, downgrade it and it goes through the customary coding and billing process post-discharge. If they determine it should be IP, the vendor does a peer-to-peer. If the denial is upheld after the peer-to-peer, a 1st (and 2nd level if necessary) appeal is sent. If, after both those appeals the denial is still upheld, we send it to an 3rd party reviewer and ultimately then up to the ALJ for final review.