169x Filetype PPTX File size 0.31 MB Source: acdis.org
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 © Proprietary Confidential Information of R1 RCM Inc. 09/05/2022 2 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) © Proprietary Confidential Information of R1 RCM Inc. 09/05/2022 3 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 © Proprietary Confidential Information of R1 RCM Inc. 09/05/2022 4 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 © Proprietary Confidential Information of R1 RCM Inc. 09/05/2022 5 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). © Proprietary Confidential Information of R1 RCM Inc. 09/05/2022 6
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