Knowledge Center

Focus on Denial Prevention and Appeal Success.

How to Handle Payer DRG and SOI Denials that Provide No Detailed Explanation

By Malissa Powers, BS, RHIT, CCS, CDIP, CICA | July 7, 2020 Although the payer should provide a detailed explanation as to why the claim is being denied, that does not always occur. The best…

Clinical Validation Denials- What Are They, and What Are They Not

By Karla Hiravi, BSN | June 10, 2020  In the medical denials and appeals world, a clinical validation audit is done to ensure billed diagnoses and conditions are validated by the medical record. If a…

Cut your Workload and Win More Appeals with Appeal Letter Templates

By Denise Wilson | October 28, 2019 There is never a reason to write an appeal letter from scratch unless you are writing your very first appeal on a particular denial type. You will never…

Why You Should Include Payer Coverage Guidelines in Appeal Templates

By Denise Wilson | October 28, 2019 Including payer coverage guidelines in your appeal letter templates can increase the efficiency and effectiveness of your appeal writing. Most payers develop and publish specific coverage and payment…

Using Evidence-Based Guidelines to Win Appeals

By Denise Wilson | October 29, 2019 The inclusion of evidence-based guidelines (EBGs) is imperative in appeal writing involving medical necessity denials, including level of care or medical necessity of a procedure or service. It’s…

The Triad of the Appeals Team

By Denise Wilson | October 29, 2019 Which knowledge area in appeal writing is the most important? Is it knowledge of the payer, knowledge of the field of medicine concerning the denial, or is it…

Speaking the Same Language as the Payer

By Denise Wilson | October 29, 2019 For a new appeal writer, learning the language of health insurance can be daunting, especially if one’s background is clinical and not business-oriented. Reading The Centers for Medicare…

Practical Steps to Reduce Insurance Denials and Steadily Improve the Bottom Line

By Kendall Smith, MD | January 30, 2020 I recently completed a comprehensive audit of closed denials for a large healthcare system. One of the major realizations that emerged was that just like Sisyphus and…

Leveraging Limitation on Liability to Win Appeals

By Denise Wilson | October 28, 2019 Limitation on Liability is a very common phrase to appeal writers, specifically when dealing with government denials. It’s a crucial argument that is vital to a winning appeal…