Tackling medical necessity denials
Editor’s note: Noelle Flaherty, PhD, RN, CPHQ, CCM, and Teri Rice, RN, MSN, MHA, MBA, CHC, will present “A Clinical Approach to Combating Medical Necessity Denials” on day one of the 2025 Revenue Integrity Symposium, which will take place September 25–26 in Westminster, Colorado. Flaherty is the director, integrated case management, CalvertHealth Medical Center, Prince Frederick, Maryland. Rice is a egulatory specialist, HCPro, Chicago, Illinois. Get an exclusive insider’s look at what RIS attendees will learn and experience at the event, discuss highlights from the agenda, and more during our upcoming free webinar! Use NAHRI’s justification letter template as a guide to gain your organization’s support for attending. Consider applying for the NAHRI Scholarship, which awards free registration to RIS (the application deadline is June 6).
Q: In what ways does your session challenge attendees to think outside the box?
Flaherty and Rice: We want attendees to think about how to incorporate the clinical staff in the revenue cycle and vice versa. They are alternative ways to combat appeals and bringing the two departments/teams together can enhance your denial prevention efforts.
Q: What’s the biggest challenge in revenue integrity and/or revenue cycle right now? How does your session help tackle this?
Flaherty and Rice: One big challenge is staying ahead of the insurance recoupment efforts by having a proactive approach. We have worked to develop a partnership between a community hospital and outside physician advisor resources. This can be expensive, but showing the return on investment can be a challenge if you are working on the back end versus upfront when the patient is still in the hospital.
Q: What’s one of the key pieces of information you would like people to take away from your session?
Flaherty and Rice: Make a business case for new programs. Do not settle for the status quo or “This is how we have always done it.”
Q: What are you most excited about for this year’s conference?
Flaherty: This year I am excited about all the other sessions. It is my first time attending the conference and I am curious to see what I can incorporate into my department’s workflow.
Q: What advice do you like to give people about revenue integrity and/or revenue cycle?
Flaherty and Rice: The biggest piece of advice we have is to understand your data. To make process changes, you need to know where to get the biggest return and getting down to the root cause is critical.