Part Three: Utilization Management Workshop Series: Best Practice Applications for the Hospital Setting (ODPT3W5039)-Utilization Management Workshop Series, Part Three Recording

Video Transcription

Video Summary

In this comprehensive webinar on managing denials and appeals in healthcare case management, presenters Bev and Tony address the growing complexity of insurance denials, especially among Medicare Advantage plans, which exhibit higher denial rates than traditional Medicare. They emphasize the importance of a robust denial and appeal process tailored to hospital size and payer types. Key challenges include confusing denials, AI-generated denial letters, administrative errors (often from registration), and frequent denials tied to medical necessity, observation status, and authorization issues.<br /><br />The session stresses collaborative efforts across departments—case management, registration, billing, compliance, and clinical staff—beginning from pre-admission through discharge and retrospective reviews. Early assessment on admission, engagement in concurrent reviews, and prompt communication with physicians and payers, including physician-to-physician peer-to-peer discussions, are pivotal to minimizing denials and maximizing reimbursement.<br /><br />Bev and Tony highlight the need to understand payer contracts, regulatory guidelines (like the two-midnight rule and inpatient-only procedures), and new Medicare Advantage requirements effective Jan 1, 2026, that bind plans to prior inpatient approvals unless errors or fraud occur. They advocate for appeals led by experienced physician advisors, the importance of thorough documentation, and educational efforts for physicians unfamiliar with utilization rules.<br /><br />Data tracking and root cause analysis are essential for targeted corrective actions, preventing recurring denials, and informing hospital committees and leadership. They underscore the role of complaints to CMS in holding plans accountable and encourage ongoing vigilance as denial rates and complexity rise. Resources such as the Association for Healthcare Denial and Appeal Management and expert podcasts supplement ongoing education.<br /><br />Ultimately, the webinar calls for a proactive, team-based approach combining education, process improvement, contract knowledge, and assertive appeals to secure appropriate payment while ensuring patient-centered care.

Keywords

healthcare denials

appeals management

Medicare Advantage

insurance denials

case management

denial rates

medical necessity denials

authorization issues

hospital size impact

payer contracts

regulatory guidelines

physician peer-to-peer

documentation importance

root cause analysis

CMS complaints