Part Three: Utilization Management Workshop Series: Best Practice Applications for the Hospital Setting (ODPT3W5039)-2025 Utilization Management Series Part 3 Presentation

2025 Utilization Management Series Part 3 Presentation

Pdf Summary

This presentation by Bev Cunningham, MS, RN, and Toni Cesta, PhD, RN, FAAN, focuses on strategies for implementing an effective denial and appeal approach to utilization management in hospitals, particularly in Georgia. It highlights the significant rise in insurance claim denials, with an average initial denial rate of nearly 12% in 2024 and emphasizes that 82% of denials are potentially avoidable. Denials occur at multiple stages: preadmission, admission/concurrent stay, discharge planning, and retrospective review after patient discharge.<br /><br />Key denial causes include inaccurate registration, failure to meet medical necessity guidelines (e.g., 2-midnight rule), incorrect billing, lack of prior authorization, and delays in treatment, especially during weekends. The presentation underscores that health insurance operates as a for-profit business, complicating claims management due to unsynchronized systems and outsourcing, contributing to denial complexity.<br /><br />Effective denial management requires preventive measures such as thorough preauthorization, concurrent medical necessity assessments, accurate documentation, and proactive communication between case managers, physicians, and payers. A strong appeals process is vital, involving peer-to-peer discussions led by physicians or advisors, backed by detailed, evidence-based appeal letters referencing payer contracts and regulatory requirements.<br /><br />Special attention is given to Medicare Advantage (MA) plans, which have specific rules such as the 2-midnight stay regulation and inpatient-only procedures. Recent regulatory updates mandate MA plans honor prior inpatient authorization unless fraud or clear error is detected, enhancing predictability for providers starting in 2026.<br /><br />The presentation advocates for tracking and analyzing denial trends to understand root causes, promote interdisciplinary collaboration, and develop corrective action plans. Transparency and education across hospital departments are critical, with denial data shared with finance, quality, case management, and utilization review committees to improve outcomes and reduce revenue loss.<br /><br />Resources and regulatory references are provided to support hospital staff in navigating the complex denials landscape, reinforcing the message: prevent denials through vigilance, track denials meticulously, appeal effectively, and continuously educate all stakeholders to enhance utilization management success.

Keywords

denial management

appeal strategies

utilization management

insurance claim denials

medical necessity guidelines

prior authorization

peer-to-peer appeals

Medicare Advantage regulations

denial trend analysis

interdisciplinary collaboration