Utilization Management Workshop Series: Best Practice Applications for the Hospital Setting Part 3-Utilization Management Series Part 3 Recording

Video Transcription

Video Summary

The video features experts Bev Cunningham and Dr. Tawny Sesta discussing challenges related to denials and appeals in healthcare, emphasizing the importance of a proactive approach, data tracking, and collaboration to address root causes of denials. Common denial reasons such as medical necessity and out-of-network insurance issues are highlighted. The speakers stress the need for understanding Medicare Advantage plans, following rules like the two midnight rule, involving expertise in denials, and sharing internal criteria. Strategies for preventing denials, handling appeals effectively, and involving dedicated staff for appeals are recommended. Attendees are advised to proactively manage denials, understand payer contracts, and appeal judiciously, focusing on medical necessity. The Association for Healthcare Denial and Appeal Management and Dr. Ron Hirsch are suggested as additional resources for support and information on the topic.

Keywords

healthcare denials

appeals

proactive approach

data tracking

collaboration

root causes

medical necessity

out-of-network insurance

Medicare Advantage plans

two midnight rule

denials expertise

internal criteria

preventing denials

handling appeals

payer contracts