Claims Recovery
A claims recovery process is essential and should incorporate all traditional processes to recover the denied payment, including informal reviews, fair hearings, administrative law judge hearings, appeal council hearings, and federal district court hearings. All levels of appeal have specific timelines,
document requirements, and dollar limits. A cost-benefit analysis should be used to determine the level of resources needed to pursue the denied claim. Use the following tips to assist each facility with claims recovery:
> Establish a department coordinator to direct all communications regarding claims recovery. This team member will ensure an efficient and timely appeal process
> Understand and meet all payer requirements for information submission. Failure to meet these timelines will result in automatic denials
> Designate one contact person to communicate with Medicare, Medicaid, and each commercial insurer
> When an employee specializes in one specific payer, he/she is more likely to be familiar with payer-specific requirements regarding appeals and information submission
> Focus appeal efforts on denials with the greatest likelihood of being reversed
> Develop a template for appealing denials questioning medical necessity
> Reach out to patient assistance programs for appeals support. Such services can reduce time and effort on the part of the hospital and increase the likelihood of successful appeals
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