• AHAP Inc.

Approach to Managing Denials

According to statistics, the average denial rate is up 23 percent since 2016 and with onset of COVID-19, denials have risen 11 percent nationally.


The question is how we can effectively address the issue of denials. To manage denials is to develop a proactive approach in which the focus will be on addressing insufficient and poor documentation from initial patient evaluation to the time of discharge. Many medical necessity denials are caused by poorly executed history and physicals lacking clinical information that accurately describes the patient’s clinical story, patient’s severity of signs and symptoms, and need for inpatient level of care.


In theory, a clinical documentation improvement program is to assure that the medical record documentation reflects an accurate picture of the patient's diagnoses, care provided for those conditions, and the quality of care provided, while the patient is receiving care.


In order to improve documentation integrity is through working with providers in strengthening and improving accuracy of documentation. In order to achieve accuracy in documentation, there must be change in physician’s behavior patterns of documentation as well as addressing documentation insufficiencies by CDI staffers. In many instances, there seems to be too much emphasize and reliance on CDI software. As a whole, CDI software must be treated as a tool and not as a crutch. The role of clinical documentation improvement (CDI) professional is ever-changing and there is a need to for individual professionals in acquiring the necessary skill sets and knowledge by staff in ensuring clinical information that supports clinical care, treatment, coding guidelines, and reimbursement methodologies.

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