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picture1_Electronic Payment System Ppt 78355 | Denials (acdis Or Wa 2018 04 06)


 169x       Filetype PPTX       File size 0.31 MB       Source: acdis.org


File: Electronic Payment System Ppt 78355 | Denials (acdis Or Wa 2018 04 06)
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 ...

icon picture PPTX Filetype Power Point PPTX | Posted on 05 Sep 2022 | 3 years ago
Partial capture of text on file.
      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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...Agenda denials commonly used terminology what we see and why root causes management prevention how cdi plays a vital role the comprehensive solution current payor trends proprietary confidential information of r rcm inc is denial anything at risk for write you expected to get paid it didn t typically categorized into groups clinical does not appear meet medical necessity no authorization lcd ncd drg downgrade technical administrative in nature timely filing definitions remit notice explanation reasons payment adjustment or non covered charges claim electronic from through claims submission system actual provider ansi code american national standards institute standardized reason codes whatever eob benefits present on contractual negotiated discount between net after applied gross total with yet vs example account balance who denies these medicare hires contractors referred as macs are fiscal intermediaries make payments behalf racs hired by audit collect overpayments hospitals qio s qu...

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