unwarranted denials IP or OP? from Specific payers UHC or Humana

pam.riddlepam.riddle
in 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.  

Comments

  • RHirschRHirsch
    Anecdotal evidence from a RAC user group is that you are not alone. Those two are the worst with inappropriate denials.
  • BCSE20BCSE20
    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.
  • jjenischjjenisch

    We also are experiencing post payment audits that result in denial of inpatient claims.  Our Coders and CDI leaders are vehement that the patient meets MCG and/or coding guidelines but the payer is using clinical results from the patient as their justification.  It seems like they are ignoring all established guidelines and making up their own to deny inpatient stays.

  • jjenischjjenisch

    If these are inappropriate denials, how do we fight them?  Nothing we seem to present to them makes a difference.

  • RHirschRHirsch
    https://forums.nahri.org/discussion/comment/515#Comment_515

    Fight with every tool you have. Do peer-to-peer appeals, remind them they cannot use the retrospectoscope to say "They got better so they never needed to be there," Give data to your contracting people so they know what's being denied. They probably have no idea. Track the number of admissions approved then denied retroactively and get the contract to prohibit that. Get your contract to specify the rules they use for inpatient and make them stick by them. If it is an MA plan and you can get the patient to complain to 1-800-MEDICARE, that gets action. MA plans hate complaints.

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