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Denial Analysis: Improving Healthcare Reimbursement
Particularly in the past few years, insurers have begun denying a larger and larger percentage of legitimate health care claims. In view of the steadily increasing costs for both managed care and indemnity coverage, this is widely viewed as a tactic to increase insurance company profits at the expense of beneficiaries. Since there is no way to prevent unfounded denials, the only recourse for providers is to appeal consistently, tenaciously, and effectively. Experience has shown that the majority of denials are overturned when a well-constructed appeal is mounted.
This increase in denials has also spawned a new industry: helping practitioners appeal denied claims. Appeal Solutions [
www.appealsolutions.com
] is one example of a company focusing exclusively on health care appeals. Although their primary emphasis is on hospital claims and medical denials, their site often has information that can be useful for P&O practices too.
They recently published an article recommending formal tracking of denials as a method to increase successful appeals. Based on the principle that "what gets studied gets improved", the gist of the recommendation is to set up a simple Excel database and record all denied claims, the steps required to appeal, and the ultimate result. Unlike simply fighting each denial in isolation, this approach makes it easy to spot trends in denials, either from specific insurers or more broadly across insurers. For example, if an increase in denials based on the limitation of coverage to "standard care" becomes apparent, you can include additional documentation in the initial filing emphasizing that the P&O care is not "deluxe" but is the minimum medically necessary to effectively treat the identified biomechanical deficit.
When denials were an occasional headache in O&P, it was practical and generally effective to deal with each incident individually. But, now that unfounded denials are more common and have almost become "standard operating procedure" for lower quality insurers, it makes more sense to challenge this growing threat to the facility in a more formal manner. To read more about this strategy, go to
www.appeallettersonline.com
.
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Ferulas para Mano, Termoplasticas.
Ciudad de México 27 de Septiembre, 2004.
Estimado John Michael CPO, FAAOP. FISPO:
Varios Terapeutas Ocupacionales desean saber si estan disponibles los Manuales sobre Ferulas Estaticas para Mano (Manual on Static Hand Splinting) (Manual o... read more
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Re: Ferulas para Mano, Termoplasticas.
Thank you, Sr. Castillo, for inquiring about Malick's excellent series of texts on hand splinting. They have been cherished volumes in my professional library for many years. Unfortunately, to the best of my knowledge, they have been out ... read more
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Roll-over shapes
re: "Evidence Based Practice", enhanced by subjective clinical measurement. Yes, it is true that "when measurement replaces estimation, calculation replaces speculation". So it's surely an advancement to be able to make relevant measurem... read more
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Re: Roll-over shapes
Well put, Harold. The more I learn about EBP, the greater my appreciation for the tremendous challenge this will present, which makes me anxious to have the field start working diligently toward this goal now. My best estimate is that it ... read more
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UCLA Text Books
Hi John,
Found recently the download version of the upper limb manual from UCLA on your website and was wondering if you could place also the lower limb manuals for a download there. Might be of some interest for aid agencies, specially ... read more
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Re: UCLA Text Books
Thanks for the words of encouragement, Marcus. Actually, funding is not that big an obstacle. I'm willing to foot the bill for scanning selected key texts into PDF files, as I have with the Spanish language P&O texts. That's a contribut... read more
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Roll over shape and Effective Foot length (EFL)
Hi John, and all...
Andrew's work on this subject is quite interesting and one that we are all having problems getting our heads around NOT because of the science involved, but because of our previously established bias. It intriguing and ... read more
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knee disartic on a 7 year old girl
I just spoke with parents of a 7 year old girl. I am concerned because of when she is older and want a cosmetic leg that isn't longer than her sound side when sitting. Plus all the great knees that she would not be able to use. She is one w... read more
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Re: knee disartic on a 7 year old girl
Sorry for being slow to respond, Matt, but I'm been assiting Marlo Ortiz with his MAS socket course at OPGA this week and we're all working from dawn until midnight every day to make it a good experience for the attendees. I just downloade... read more
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Re: knee disartic on a 7 year old girl
Matt,
Persons more experienced in pediatric prosthetics might confirm my position that the K.D. level is unquestionably the ideal transfemoral level for a 7 yr old because the amputated femur will not reach the same length as the sound fe... read more
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Re: Re: knee disartic on a 7 year old girl
Absolutely correct, Dave. Thanks for responding. --John Michael CPO
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Re: Re: Re: knee disartic on a 7 year old girl
Sorry Mike, I'm a bit punchy from lack of sleep...
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Re: knee disartic on a 7 year old girl
Ciudad de Mexico 7 de Septiembre, 2004.
Estimado John Michael CPO: de acuerdo a nuestra experiencia el mejor nivel de amputacion en niños es la desarticulacion en cualquier articulacion. El riesgo que se toma en una amputacion transtibial ... read more
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Re: Re: knee disartic on a 7 year old girl
Thanks Sr. Castillo- I agree fully with your assessment. --John Michael CPO
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