It is relatively easy to identify the root cause of an inpatient denial due to a procedural matter like failure to obtain an authorization. But what is the root cause of an inpatient denial when the hospital does everything ‘right’? They notify the correct insurance company on time. They obtain the authorization and provide clinical details to support the inpatient admission. And still, the payer denies the inpatient admission at the time of request opining the inpatient level of care is not medically necessary – that the patient can be treated at a lesser level of care.
This session explores why uncovering subjective decision-making, on both the provider and payer side, is the biggest challenge hospitals face in preventing clinical denials. In detail, we review the importance of analyzing and trending seven key data points that are within the hospital’s EPIC instance.