There is one relatively easy way hospitals can reduce claims denials: better clinical documentation.
Insurance companies require documentation, and it is often the leading factor in level of care and admission denials. The importance of providing complete documentation never goes away. Treating physicians and utilization review managers must ensure that every admission includes:
- All the significant factors of a patient’s current health status
- The patient’s comprehensive health history
- The complete thought process that went into admitting the patient
- The treatment plan
Without this documentation, cases are much more likely to be denied or pushed to a lower level of care by the insurance provider.
A treating physician worried about a particular condition that is not documented in the patient’s records translates to no worry for the insurance reviewer. Since they will have no documentation of this concern, it becomes a non-factor in the approval. This is especially important when it comes to assessments. If the treating physician has a plan for assessment, it must be included in the treatment plan and it needs to be thorough and updated daily. The insurance company needs to see the documented, detailed, and updated treatment plan that proves a higher level of care is warranted or that the resources at a higher level of care are necessary for the proper management of the patient’s presenting medical problems in order to approve the plan. If important pieces of the plan are not communicated to the insurer through documentation, it may result in denial for level of care.
Take the following case as an example, last year a patient with COVID-19 was admitted to the hospital but the inpatient level of care was denied by Aetna and instead approved as an observation stay. An external Peer-to-Peer review was held between a Case Review Physician (CRP) representing the hospital and a doctor representing the insurance company to review the denial. The CRP focused on the patient’s elevated blood sugars and his increased risk for poor control while on Decadron. The CRP also focused on the escalation of therapy with Remdisivir the day prior to discharge. The discussion with the insurance medical director resulted in the denial being overturned as he agreed the patient warranted inpatient level of care. Had all these factors been well documented initially, the denial may not have happened.
“Preventing claims denials and medical necessity reviews hinges on good clinical documentation … Hospitals can be proactive by ensuring clinical documentation supports the course of treatment, making it easier for utilization reviewers and payers to make a final decision about appropriateness.” 1