The key for obtaining the necessary cooperation is Education. Yes, I mean Education with a capital “E”: not a series of memos or a few conferences, but a campaign of ongoing Educational programs that will require efforts beyond what your facility previously has put forth. After all, we are in a new era with CMS, and new times call for new measures. If your facility depends on CMS dollars, you must ensure that revenue opportunities are not lost due to inadequate physician documentation.


Every hospital has a unique culture and set of resources, yet whether your facility grows your physician education program from within or with the help of consultants and vendors, multiple modalities will be required. Following are two important keys to success:


#1: Develop a Medicare management tool that reports denials at the physician level.

In the RAC Demonstration project, the Claim RACs reported that 40 percent of all overpayments were due to allegedly medically unnecessary services. In my experience successfully appealing many of these denials, I have found that many such services were actually medically necessary, but the physician documentation was less than ideal in communicating the need for them. Hence, many denials are not overturned until the Administrative Law Judge level (an area of particular confusion is the Outpatient vs. Observation vs. Inpatient status).


An excellent way to determine where to target educational efforts simply is to sort and compare data on audit results or on denials by responsible physicians. The cost of every physician’s denied claims can be tabulated, and the results can be quite motivating for all involved in denial prevention.

#2: Involve treating physicians in the appeal process to the fullest extent practicable.

This part is a bit tricky. Physicians generally do not have the requisite training or experience to determine how to best evaluate and present a case in the appeal process. Furthermore, they may not have the time or inclination, as their focus is understandably on the practice of medicine. However, with respect to inspiring physicians to change their medical record documentation practices, I have found that they learn best by getting involved with actual examples of less-than-ideal medical records via the appeal process.


One method of minimizing the effort and expertise required by physicians is to use a team approach for the appeal process. For instance, a denied claim can be analyzed first by those with expertise in Medicare criteria and techniques of best practice appeal presentation; the physician does not need to be consulted at this stage unless there is need for clarification. If a meritorious claim is not overturned at the redetermination or reconsideration level, then the physician (or medical director of the facility) should be brought in to testify at the Administrative Law Judge hearing level. The physician will have the benefit of the analysis already being prepared, and the hearing process will enable him or her to learn firsthand what is required for a medical record to communicate clearly the necessary elements for medical necessity.



About the Author

Linda Fotheringill, Esq, is a founding member of Washington West, LLC, and is a nationally recognized expert on Denial and Appeals Management. Ms. Fotheringill successfully assists hospitals across the country, overturning “hopeless” denials and generating millions of dollars in otherwise lost revenue.

Linda Fotheringill is the Co-Founder & Principal of Washington & West, LLC

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