Denials

Management
Medicare Compliance
Training Handbook

Denials
Management
Training
Handbook

Tanja Twist, MBA/HCM

Denials Management Training Handbook is published by HCPro, a division of BLR.

Copyright © 2017 HCPro, a division of BLR

All rights reserved. Printed in the United States of America. 5 4 3 2 1

ISBN: 978-1-68308-147-0

No part of this publication may be reproduced, in any form or by any means, without prior
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Tanja Twist, MBA/HCM, Author

Nicole Votta, Editor
Andrea Kraynak, CPC, Associate Product Manager
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 Table of Contents
About the Author...................................................................................... iv

Chapter 1: Understanding Denials...........................................................1

Basic Types of Denials................................................................... 3

Regulatory Impacts....................................................................... 9
Contract Language and Payer Manuals....................................... 17

Chapter 2: Capturing Your Denial Data.................................................21

Remittance Advice Review.......................................................... 21

Denials Management Software – Building a Denials Database...... 23

Chapter 3: Managing Your Denials........................................................27

Building an Effective Denials Management Team....................... 27

Data to Monitor ......................................................................... 28
Creating a Denial Dashboard...................................................... 29
Working Denials......................................................................... 30
Handling of Upheld Denial Outcomes........................................ 33

Chapter 4: Denial Prevention and Best Practices..............................35

Tracking Outcomes..................................................................... 35
Identifying and Correcting Internal Root Cause Issues............... 35

Appendix A: Sample Appeal Letters/Templates................................39

Appendix B: Helpful Websites...............................................................45

Appendix C: Denials Assessment Tool.................................................47

Appendix D: List of Downloads.............................................................49

© 2017 HCPro Denials Management Training Handbook iii



About the Author

Tanja Twist, MBA/HCM

Tanja Twist, MBA/HCM, has more than 25 years of experience

in healthcare revenue cycle management, with a focus on reim-
bursement and denials management. She has held the position of
director of patient financial services, as well as overall operations
officer for large and small hospital facilities, professional providers,
and provider groups. Twist currently works for the University of
California Los Angeles (UCLA) Health Systems. She advocates for
hospitals and providers nationwide, providing revenue cycle
management services supported by a deep knowledge of state-
specific issues and unparalleled expertise in Medicare, Medicaid,
and commercial reimbursement.

Twist has a bachelor’s degree in business management and a

master’s degree in business administration with a certification
in healthcare management. She is a nationally recognized speaker
on governmental recovery programs, commercial denials, and
best practices to avoid audits. Twist is on the board of the Western
Region chapter of the American Association of Healthcare
Administrative Management (AAHAM), was a board member
for the Workgroup for Electronic Data Interchange (WEDI), and
is an active member of the Southern California chapter of the
Healthcare Financial Management Association (HFMA).

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CHAPTER 1

Understanding Denials
Denials management is a frequent discussion topic among revenue
cycle professionals. Yet despite the continued focus, most industry
statistics reveal that, on average, providers write off between 3%
to 5% of their net revenue to denials every year. These providers
are not ignoring their denials; in fact, most would likely say they
have a denials management process in place. However, few have
a program that not only tracks and trends denials but also uses
that data to identify the root causes of their denials or takes the
necessary corrective actions to prevent them from occurring in the
future. Without such a program, the revenue bleed will continue
to repeat itself year after year.

Today’s revenue cycle leaders are struggling to maintain positive

financial margins in an audit-heavy environment. The number of
audited claims has increased substantially over the past 10 years
as government programs and commercial payers have placed an
increased focus on their own financial viability through aggressive,
and often overwhelming, audit programs that providers may
struggle to comply with. This has led to what can be viewed as
a reactive or even passive environment instead of a proactive
environment, often due to resource and budgetary constraints.
Most providers pull and submit records for the pre- and post-
payment audit probes, and many file appeals for denied claims

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Chapter 1

either internally or through a vendor. However, most fail to form-

ally identify and correct the root causes of the claim issues
triggering the probes and denials. In doing so, they subject them-
selves to continued and likely increased audits and denials. The
bigger concern, however, in not correcting the systemic problem is
that the provider can be targeted for focused pre-payment or post-
payment medical reviews by CMS, Medicare Administrative
Contractors (MAC), Recovery Audit Contractors (RAC), Compre-
hensive Error Rate Testing (CERT), or other claim review con-
tractors. If the results of these reviews identify potential fraud, the
provider can then be referred to the appropriate Medicaid Zone
Program Integrity Contractors (ZPIC) for further investigation.

The purpose of this handbook is to illustrate the process by which

providers can effectively decrease the percentage of revenue being
written off to denials each year, as well as significantly decrease
compliance risks. This is not a promise to stop the appeal programs
from probing your facility, but rather to provide proven methods
to not only manage but also prevent repeat denials and ultimately
decrease your denial write-off percentage. While this method does
require additional resources and time in the beginning, it will
pay for itself in the end by making your organization smarter in
identifying and correcting the key issues that are driving your
current denials, and in ultimately preventing future audit requests
for those claims. It is important to remember that auditing firms
learn from the organizational data they gather. During a probe, if
they find any issues, you can be sure that additional audit requests
will follow. However, once the data you provide in response to
these probes or audit requests demonstrate that the issue is no

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 Understanding Denials

longer occurring, they will stop auditing those claims. While they
may shift their focus to other areas, if you take the necessary steps
to move your organization from one that merely manages denials
to one that proactively identifies and prevents them, you will stay
one step ahead of the auditors.

Basic Types of Denials

The first step in any effective denials management program is to

develop an understanding of what constitutes a denial, as well as
the different types of denials and their contributing causes. Once
this knowledge has been established, providers can begin to
capture and categorize denials by their specific reason and dollar
value, allowing a deep dive into the type(s) of services being
denied, the type of claim, and the physician, payer, department,
person, or situation that caused the denial. Although there are a
large number of denial reason codes used throughout the industry,
all of them generally tie back to a few basic denial types: medical
necessity or clinical denials, technical denials, and beneficiary
coverage or benefit denials.

Medical necessity or clinical denials

Medical necessity or clinical denials are typically a top denial
reasons for most providers and facilities. They are also known as
hard denials, in that they require an appeal to request reconsider-
ation. Denial reasons that fall under this category include:

•• Inpatient criteria not being met

•• Inappropriate use of the emergency room

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Chapter 1

•• Length of stay

•• Inappropriate level of care

The primary causes of medical necessity denials are the:

•• Lack of documentation necessary to support the length

of stay

•• Service provided

•• Level of care

•• Reason for admission

Providers must ensure that their physician and nursing documenta-

tion clearly supports the services billed for and that the physician’s
admission order clearly identifies the level of care. One of the most
effective means of ensuring compliance is through the implementa-
tion of a clinical documentation improvement (CDI) program. This
can either be an internal program or outsourced to a qualified
vendor. A successful CDI program facilitates the accurate
documentation of a patient’s clinical status and coded data.

Implementing a successful CDI program is typically one of the

most challenging pieces of the denials management process, but it
is the most important for long-term success. The first step is to
obtain the support of the executives and physician leadership
within the organization. Second, but equally important, is
identifying a physician champion or physician advisor role. This
role is critical, as he or she will be the liaison to the physicians,

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 Understanding Denials

reviewing chart documentation and providing feedback on how to

prevent denials moving forward.

Utilization management issues

Another of the most common categories of denials is authorization
issues, which includes:

•• Lack of authorization

•• Failure to notify a health management organization

(HMO) or at-risk medical group of an admission from the
emergency room

•• Authorizations for a different level of service

•• Lack of, or inconsistent, daily certification

Providers should ensure that all scheduled procedures or non-

emergent admissions are authorized or certified prior to services
being rendered. For unscheduled or emergent admissions, HMOs
require authorization of services and notification of admissions
from the emergency room once the patient has been stabilized.
Preferred provider organizations (PPO) may also require an
authorization or initial certification for the service or admission,
along with daily clinical certification throughout the stay. Failure
to do so can prompt a denial of the noncertified days billed or the
level of care provided. These denials require appeals, which result
in a significant delay in account balance resolution, as well as an
increase in staff resources needed to resolve an account.

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Chapter 1

Technical denials
Any nonclinical denial can be categorized as a technical denial.
Technical denials are also known as preventable denials. Causes
of technical denials can range from contract terms and/or language
disputes, coding-related errors, data entry or registration errors,
charge entry errors, and charge data master (CDM) errors. Other
technical denials may be caused by claims submission and follow-
up deficiencies and denials pending receipt of further information,
such as medical records, itemized bills, an invoice for an
implantable device or drug, or receipt of the primary explanation
of benefits (EOB) for a secondary payer claim.

It is imperative that your claims are submitted in adherence with

federal, state, and individual health plan requirements and that
your claims are submitted timely. Other claim submission errors
can be caused by claims being sent to the wrong address or even
the wrong payer. Technical denials are known as soft denials
because they can usually be reprocessed by providing a corrected
claim or other additional information to the payer.

Coverage/plan denials
The majority of coverage or incorrect plan denials are the result of
process failures during the registration of the patient’s account.
These denials include:

•• Incorrect demographic information

•• Lack of coverage at time of service, patient plan

benefit restrictions

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 Understanding Denials

•• Limitations and misdirection of the claim when an

HMO is involved

Demographic denials can be eliminated by verifying the patient’s

address and ensuring that the name and date of birth received and
entered into your computer system match that of the insurance
company. Date of birth errors are often due to a typographic error
by the provider but can also be caused by data entry errors on
the part of the insurance company. To prevent name mismatch
errors, it is important that the patient and subscriber names
entered into the provider’s computer system match those found
on the insurance card. Most common problems are the result of
using a patient’s familiar name instead of his or her legal name
(for example, Pat versus Patricia) or the lack (or inclusion) of a
middle name or initial.

Benefit denials are most commonly the result of a provider’s failure

to verify the patient’s specific plan benefits during the insurance
verification process. Verifying benefits can identify coordination
of benefit issues, beneficiary plan coverage or out of network
coverage restrictions, and eligibility termination due to lack of
premium payment. With the expansion of coverage as a result of
the Affordable Care Act (ACA), it is not only imperative to verify
eligibility and benefits at the time of admission or service, but also
to develop a process for re-verification at the first of each month for
hospital stays and other services that span from month to month.
This process should not be a new concept for providers, as
employer group health insurances have historically presented these
types of issues. However, post-ACA, the industry has noticed a
dramatic increase in coverage denials due to plan termination.

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Chapter 1

Initial claim submission issues

Many initial claim submission or payer rejection errors can be
eliminated by ensuring that the claim submission (bill scrubber)
software or vendor uses robust, current edits, specific to each
payer and type of service being billed. It is equally important for
providers to routinely audit reports that capture edits that their
billing staff are encountering and either correcting or overriding.
This data should be used to correct the root cause of the issue
causing the edit to fire.

Misdirected claims for managed care health plans, resulting from a

provider’s failure to follow the division of financial responsibility
(DOFR) between the health plan and their contracted medical groups
or capitated hospitals, usually make up the majority of technical
denials. The DOFR defines the at-risk entity (where the claim should
be submitted) for the specific types of services provided. Providing
education and cheat sheets or copies of the individual DOFRs to
both the registration department and the billing departments, as
well as ensuring staff are educated on correctly identifying the
true responsible entity, is the best mechanism of defense.

Account follow-up denials

Denials can also be received for failure to provide information
requested by the insurance company, such as medical records,
itemized bills, or copies of invoices. Ensuring timely, thorough
follow-up on correspondence with the insurance company will
help to eliminate these denials. For payers who require that the
documentation be submitted with the claim, a good prevention
technique is to create a billing edit that holds applicable claims

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 Understanding Denials

until the documentation necessary for submission has been

obtained and submitted with the initial claim.

Regulatory Impacts

The logic behind most denials can be traced back to language in

payer contracts or various regulatory statutes. Although the impact
on claims submission and reimbursement are obvious in some
cases, such as CMS’ specific guidance on claims submission and
billable services, there are many state and federal regulations that
may ultimately impact claims and denials. An understanding of
the major regulations will aid in appeals and guide efforts to
prevent denials on the front end.

Regulatory statutes
Regulatory statutes are a large contributor of denials due to an
increased focus on fraud and abuse. The Health Insurance
Portability and Accountability Act (HIPAA) of 1996 established a
national healthcare fraud and abuse program, which has led to the
introduction, or ramping up, of a number of federal and state audit
programs, such as CMS’ RAC program (CMS, Medicare Fee for
Service Recovery Audit program, 2016), CERT program (CMS,
Comprehensive Error Rate Testing, 2016), ZPIC (MLN Matters,
2012), the Medicaid Integrity Program’s (MIP) Audit Medicaid
Integrity Contractors (Audit MIC) (CMS, Medicaid integrity
program, 2015), the Payment Error Rate Measurement (PERM)
audits (CMS, Payment error rate measurement, 2016), and the
Office of Inspector General (OIG) (OIG, 2016) just to name a few.
Each of these programs has unique nuances regarding their scope

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of service and provider response and appeal process. It is

imperative that providers continually monitor these programs,
ensure compliance, and establish response policies for each one.

CMS guidelines
CMS publishes coverage determinations for items and services at
both a local and national level. While the majority of these are
local coverage determinations (LCD), occasionally CMS determines
the need to publish a national coverage determination (NCD),
which applies to all Medicare providers regardless of their Medicare
Administrative Contractor (MAC). Compliance with both applicable
MAC-published LCDs and the NCDs is a critical element for a
provider to effectively manage and prevent denials for Medicare
and Medicare Managed Care claims. Each MAC will publish a
database containing open (current) and closed (archived) LCDs on
their respective websites (CMS, NCDs Alphabetic Index, 2016).

Recovery Audit Contractors

Most providers have experienced audits and denials resulting from
CMS’ RAC program, now also known as Recovery Auditors (RA).
In its Fiscal Year 2014 Executive Summary to Congress (CMS,
2014), CMS reported that $2.3 billion dollars was collected in RAC-
identified overpayments during fiscal year 2014. The following
three primary areas were identified as the causes of the most
common improper payments:

•• Payment is made for services that do not meet Medicare’s

coverage and medical necessity criteria

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 Understanding Denials

•• Payment is made for services that are incorrectly coded

•• Payment is made for services where the documentation

submitted does not support the ordered service

The total amount of overpayments collected by the RAC program,

from fiscal year 2010 through fiscal year 2015, was a staggering
$9.6 billion (CMS, 2015). Although CMS outlined the three primary
reasons for improper payment, providers must still be diligent
about monitoring CMS’ RAC website, as well as the website for
their assigned regional Recovery Auditor, to stay up to date on
additional areas of concern (CMS, Medicare fee for service recovery
audit program, 2016). The top causes of denials vary from year to
year. For example, the CMS 3rd quarter 2016 RAC data identified
the top issues nationally causing provider denials as MS-DRG
coding validation for sepsis and infections, as well as outpatient
therapy claims that registered above the $3,700 threshold for both
skilled nursing facilities and outpatient hospitals (CMS, Quarterly
newsletter, 2016). These data reflect different areas of concern from
the data reported in 2014, and 2017 data will likely highlight other
areas of concern.

References and websites related to the Medicare RAC program can

be found in Appendix B.

On October 31, 2016, CMS announced the award of the new

Medicare Fee-For-Service RACs:

•• Region 1: Performant Recovery, Inc.

•• Region 2: Cotiviti, LLC

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•• Region 3: Cotiviti, LLC

•• Region 4: HMS Federal Solutions

•• Region 5: Performant Recovery, Inc.

The RACs in Regions 1 through 4 will perform post-payment reviews

to identify and correct Medicare claims that contain improper
payments (either overpayments or underpayments) that were
made under Medicare Part A and Part B for all provider types other
than durable medical equipment, prosthetics, orthotics, supplies
(DMEPOS), and home health/hospice. The Region 5 RAC will be
dedicated to the post-payment review of DMEPOS and home health/
hospice claims nationally (CMS, News & announcements, 2016).

A sample RAC tracking dashboard is available on the downloads

page for this book at www.hcpro.com/downloads/12561.

Medicare Outpatient Observation Notice (MOON)

The Notice of Observation Treatment and Implication for Care
Eligibility (NOTICE) Act was signed into law August 6, 2015, and
becomes effective March 8, 2017. The NOTICE Act requires
hospitals and critical access hospitals to provide written and oral
notification to individuals receiving observation services as
outpatients for more than 24 hours. The written notification must
take the form of a document called the Medicare Outpatient
Observation Notice (MOON). Initially, the Medicare Advantage
population was excluded from MOON; however, as of August 6,
2016, Medicare Advantage patients are included in the MOON
requirements.

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 Understanding Denials

The written notice must be delivered no later than 36 hours after

observation services are initiated and must include:

1. The reason the individual is receiving observation services

2. An explanation of the implications of receiving outpatient

observation service

a. Cost sharing

b. Post-hospitalization eligibility for Medicare

coverage of skilled nursing facility services

The hospital must obtain the signature of the individual or individual

acting on behalf of the patient. Hospitals must deliver a hard copy
of the MOON to beneficiaries and enrollees. Hospitals must retain a
copy of the signed MOON and may store the MOON electronically.
The beneficiary must be given a paper copy of the signed MOON—
even if the signature is captured digitally. Hospitals are permitted
to give the MOON by telephone provided a hard copy is delivered
to the representative (CMS, 10611, 2016).

Compliance with the NOTICE Act and the MOON requirement will
likely prove to be the source of future probes and/or audits by
CMS. Failure to produce a countersigned copy of the completed
MOON form for an observation claim spanning more than 24 hours
upon request would find the hospital in violation of the NOTICE
Act. Hospitals must ensure that they have developed policies and
procedures to incorporate accurate and timely completion of the
MOON form into their processes for observation cases spanning
more than 24 hours for both Medicare-fee-for service and Medicare

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Advantage populations beginning no later than March 8, 2017.

More information on the MOON, including a blank MOON form, is
available on the downloads page for this book at www.hcpro.com/
downloads/12561.

Federal guidelines
A number of federal guidelines contain language that directly
impact provider billing. Sometimes, this language may exist as a
subsection of a law that, on the surface, has little to do with
medical billing or beneficiary rights and limitations. Organizations
that are unaware of the full scope of federal guidelines put
themselves at an unnecessary risk of increased denials and
noncompliance.

Employee Retirement Income Security Act of 1974

The Employee Retirement Income Security Act of 1974 (ERISA), a

federal law that applies to many private employers, establishes
minimum standards for retirement (pension plans), health, and
other welfare benefit plans (including life insurance, disability
insurance, and apprenticeship plans) to protect employees and
employers. ERISA applies to private (nongovernment) employers
offering employer-sponsored health coverage and some other
benefits to their employees. It does not require employers to offer
any specific types of insurance or retirement plan but does set
minimum standards for some of the benefits that an employer
does offer to employees. ERISA laws do not apply to privately
purchased, individual insurance policies or benefits (USDL, 2016).

The Benefit Claims Procedure Regulation (BCPR), a subsection of

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 Understanding Denials

ERISA (29 CFR 2560.503-1), stipulates how benefits are determined

when an employee files a claim. It controls how claims, appeals,
and decisions can be made, as well as discloses rights for employees
who make claims. The BCPR regulation created important new
patient protections to ensure that group health plan participants in
the managed care environment have access to a faster and fairer
process for benefit determinations (USDL, Fact sheet, 2000).

At face value, ERISA appears to be unrelated to provider or facility

operations. This could not be further from the truth. ERISA and the
specific stipulations outlined in the BCPR are directly applicable to
healthcare provider claims. The regulations refer to an “authorized
representative.” When a claim involves urgent care, a plan must,
without regard to the plan’s procedures for identifying authorized
representatives, permit a healthcare professional with knowledge
of the claimant’s medical condition (e.g., a treating physician) to
act as the authorized representative of the claimant. This exception
is intended to enable a healthcare professional to pursue a claim on
behalf of a claimant under circumstances where, for example, the
claimant is unable to act on his or her own behalf (USDL, Group
health and disability plans, 2012).

State regulations
Managed care denials are complicated by the division of financial
responsibility. In some cases, the service is the financial responsi-
bility of the health plan, and in others it’s the responsibility of
the medical group. One of the largest issues contributing to
managed care denials is the failure of the provider/facility to
provide timely notification to the plan or medical group of an

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Chapter 1

admission. Establish-ing a process for ensuring timely notification

will significantly reduce denials or delays in payment. Often, payers
or medical groups will not respond to the provider’s initial notifi-
cation in a timely fashion and then deny post-stabilization care.

In California, guidelines for timely notification and payer response

are outlined in the California Health and Safety Codes, Article 5,
otherwise known as the Knox-Keene Healthcare Service Plan Act of
1975 (California, 2016). Section 1371.36(a) states:

A health care service plan shall not deny payment of a claim

on the basis that the plan, medical group, independent practice
association, or other contracting entity did not provide authori-
zation for health care services that were provided in a licensed
acute care hospital and that were related to services that were
previously authorized, if all of the following Article 5, §§1367—
1374.195 Knox-Keene Act 2016 277 conditions are met: (1) It
was medically necessary to provide the services at the time. (2)
The services were provided after the plan’s normal business
hours. (3) The plan does not maintain a system that provides
for the availability of a plan representative or an alternative
means of contact through an electronic system, including voice-
mail or electronic mail, whereby the plan can respond to a
request for authorization within 30 minutes of the time that a
request was made. (b) This section shall not apply to investi-
gational or experimental therapies, or other non-covered services.

Section § 1371.4(d) states:

If there is a disagreement between the health care service plan

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 Understanding Denials

and the provider regarding the need for necessary medical

care, following stabilization of the enrollee, the plan shall
assume responsibility for the care of the patient either by
having medical personnel contracting with the plan personally
take over the care of the patient within a reasonable amount
of time after the disagreement, or by having another general
acute care hospital under contract with the plan agree to
accept the transfer of the patient as provided in Section 1317.2,
Section 1317.2a, or other pertinent statute. However, this
requirement shall not apply to necessary medical care provided
in hospitals outside the service area of the health care service
plan. If the health care service plan fails to satisfy the
requirements of this subdivision, further necessary care shall
be deemed to have been authorized by the plan. Payment for
this care may not be denied.

While the regulations cited above are specific to the state of Cali-
fornia, there may be similar statutes in other states. I encourage
readers to research and understand their own state regulations and
not to accept a payer or medical group’s denial in blind faith.

Contract Language and Payer Manuals

Contract terms can be a large contributor to a provider’s denials.

This can be caused by a misinterpretation of the intent of a
contract’s terms. This is often seen in the calculation of stop-loss
and exclusions (carve-outs) within the rate structure of a contract.
Other areas that can cause underpayments are the language within
the body of a contract and a health plan’s provider billing or
operation’s manual. Providers must use caution when negotiating

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their contracts to ensure the intent and language are clear. It is

also equally important that providers download and understand
payer-specific billing and appeal requirements outlined in both the
contract and the payer’s billing and operations manuals.

References
Centers for Medicare & Medicaid Services (CMS). (2016). Medicare fee for service
recovery audit program. Retrieved from www.cms.gov/research-statistics-data-and-
systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/.
CMS. (2012). The role of the zone program integrity contractors (ZPICs), formerly the
program safeguard contractors (PSCs). MLN Matters, SE1204. Retrieved from www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
downloads/SE1204.pdf.
CMS. (2014). Recovery auditing in Medicare for fiscal year 2014. Retrieved from
www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-
Compliance-Programs/Recovery-Audit-Program/Downloads/RAC-RTC-FY2014.pdf.
CMS. (2015). Medicaid integrity program. Retrieved from www.cms.gov/Medicare-
Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/index.html?redirect=/
medicaidintegrityprogram/.
CMS. (2015). National program total corrections. Retrieved from www.cms.gov/Research-
Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/
Recovery-Audit-Program/Downloads/National-Program-Total-Corrections.pdf.
CMS. (2016). Comprehensive error rate testing. Retrieved from www.cms.gov/
Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-
Programs/CERT/.
CMS. (2016). Details for title CMS-10611. Retrieved from www.cms.gov/Regulations-and-
Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10611.html.
CMS. (2016). National coverage determinations (NCDs) alphabetic index. Retrieved
from www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.
aspx?bc=AgAAAAAAAAAAAA%3d%3d&.
CMS. (2016). News & announcement. MLN connects provider enews. Thursday, November
3, 2016. Retrieved from www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/
Provider-Partnership-Email-Archive-Items/2016-11-03-eNews.html#_Toc465834795.

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CMS. (2016). Payment error rate measurement. Retrieved from www.cms.gov/Research-

Statistics-Data-and-Systems/Monitoring-Programs/Medicaid-and-CHIP-Compliance/PERM/
index.html?redirect=/perm.
CMS. (2016). Quarterly newsletter. Retrieved from www.cms.gov/Research-Statistics-
Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-
Audit-Program/Downloads/MedicareFFS-Recovery-Audit-Program-3rd-Qtr-2016.pdf.
Office of Inspector General (OIG). (2016). Fraud. Retrieved from https://oig.hhs.gov/fraud/
State of California Department of Managed Health Care. (2016). Regulations applicable
to California licensed health care service plans. Retrieved from https://wpso.dmhc.ca.gov/
regulations/docs/16CCRp.pdf.
United States Department of Labor (USDL). (2016). Frequently asked questions. Retrieved
from http://webapps.dol.gov/dolfaq/go-dol-faq.asp?faqid=225.
USDL. (2000). Fact sheet. Retrieved from www.dol.gov/ebsa/newsroom/fs112000.html.
USDL. (2012). Compliance assistance: Group health and disability plans. Retrieved from
www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/programs-and-initiatives/
outreach-and-education/hbec/CAGHDP.pdf.

© 2017 HCPro Denials Management Training Handbook 19

The process for dealing with claim denials and appeals can be time-consuming.
Confusion around complex regulations may unnecessarily prolong the process
and negatively impact a hospital’s revenue cycle.

An effective denials management program requires clear goals and a mission

that results in value to the hospital. A denials management program is not only
a key part of revenue integrity, it can provide valuable data hospitals can use
to analyze performance across various departments, identify pain points, and
support overall operational improvements.

The Denials Management training handbook is a clear, concise guide to the

denials management process. Best practices and tips will help hospitals turn
denials into successful appeals.

TDMTH

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