RCM tip of the day: For concurrent denials, use a clinical narrative in peer-to-peer reviews

A peer-to-peer review process using predictive analytics can help healthcare organizations with denial management, according to Heather Bassett, MD, CMO of XSOLIS.

Dr. Bassett shared the following advice with Becker's Hospital Review:

"For concurrent denial determinations, the peer-to-peer medical review process often offers the best opportunity to get a case mediated before the overall revenue impact becomes substantial — therefore, maximizing this brief window of opportunity is crucial. With only one shot, an effective peer-to-peer review process requires three things: the right data, the right format and the right approach.

"Despite most organizations' efforts to overturn denials early, the peer-to-peer review process often goes unsupported and can transform into a conflict conversation based on opinion, not data. Technology that uses predictive analytics to create a story around medical necessity rather than just shows a myriad of data points makes the process more efficient and equips the physician to have a productive conversation with the payer. As the ultimate peer-to-peer decision is dependent on the information presented, generating an automatic clinical narrative helps physicians capture all relevant data points and ensures data that could potentially be lost or overlooked becomes meaningful and persuasive. This results in a higher overturn rate for concurrent denials and a protected revenue stream."

If you would like to share your RCM best practices, please email Kelly Gooch at kgooch@beckershealthcare.com to be featured in the "RCM tip of the day" series.


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