Denials and Appeals

Although commercial payers typically pay more per claim, it is significantly easier for providers to get reimbursed by Medicare, according to a May 2023 Crowe Revenue Cycle Analytics report.

The Office of Inspector General (OIG) recently released an audit report on prior authorization and payment denials by Medicare Advantage Organizations (MAO). The result raised OIG concerns about certain MAO denial practices impacting beneficiary access to medically necessary care.

While some people choose to manage denials by using “zone defense,” others opt for a targeted approach.

Map a course to revenue integrity success.

Learn what claims are coming under heightened payer scrutiny and how to prepare for increased audit activity.

Apply these tips to improve your organization’s denial management program.

Get ahead of denials by making strategic use of data.

Denial rates are continuing to rise, according to a November 2022 Crowe report on revenue and expense issues in healthcare.

CMS released a proposed rule on December 6 to promote transparency, efficiency, and automation in prior authorization processes. Certain requirements in the proposed rule are also intended to improve data accessibility for patients, providers, and payers.