Clinical Denials and Appeals Recorded Webinar | Beverly Cunningham | From: Dec 15, 2020 - To: Dec 31, 2020 |
Aligning with the revenue cycle when there are clinical denials, is a challenging process for the hospital case management department. The financial aspect of the revenue cycle receives denials for medical necessity, but payers may just be placing a particular denial in a medical necessity bucket, when in fact the denial is unrelated to clinical medical necessity. It is critical for the hospital case management department to develop their own process for receiving denials related to them. That process should also include categorization of the reasons for denials related to them. As these denials are categorized, they should also be assessed to understand the reason for the denial and any related aspects contributing to the denial (such as which RN case manager or social work case manager, which unit, which payer, which nursing unit, for example).
There should be a process developed for sharing information about denials, including the physician advisor in the assessment of denials and the development of an improvement process to ensure those denials can decrease in the future. For this to be an effective process, there must be appropriate roles in place in the department to allow for focus and improvement of denials.
Learning Objectives:-
Why Should you Attend?
Utilization management was the first role applied in acute care case management models. It has been the foundation of case management. Case management leaders struggle to incorporate utilization management with the other roles of the department—care coordination, discharge planning, and resource management. Today’s challenge is to integrate all roles with the utilization management process. In the value-based reimbursement environment, the utilization management process is critical to assure cost-effective care. As providers, in this circumstance, the hospital, assume more of the cost, utilization management must be a collaborative initiative—collaborative with all case management department members, with physicians, with nursing, and with other ancillary departments.
This webinar will focus on the appeal and denial process of the case management role. It will focus on processes and roles to support identifying your clinical denials and improving denials with negative trends.
Who Should Attend?
Beverly Cunningham is a founding partner of Case Management Concepts, LLC. She has a 25-year deep working knowledge of case management with specific expertise in denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process. She has served as a Commissioner on the Commission for Case Management Certification and is a fellow with the Advisory Board.
Bev is also former Vice President Resource Management at Medical City Dallas Hospital where she had responsibility for Case Management, Health Information Management, Patient Access, Physician Integration and Solid Organ Transplant. As a Clinical Assistant Professor for the Master of Nursing Program at the University of Oklahoma, she coached students in their clinical practicums.
Bev is a well-known speaker in the Case Management field. Her publications include a chapter CMSA's Core Curriculum for Case Management Certification and most recently, co-author of the book, Core Skills for Hospital Case Management.
Bev has a BSN from Pittsburg State University, Pittsburg, Kansas and a Master of Science, Nursing Major, from the University of Oklahoma. She is certified in case management (ACM) by the American Case Management Association.
