Physicians are becoming more and more familiar with case review as the standards for approving care in the Medicaid, Medicare, and
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Managed Care Environment become more stringent. In order to ensure that you receive maximum reimbursement for the services provided, it is important that you optimize your cases for review prior to sending them to a Physician Advisor. Here are five simple steps to optimize your cases for review:
1. Documentation- Ensure that your documentation is complete and sufficient – Surprisingly the number one cause for denials is absence or inadequate information. Fill out all appropriate areas of your case providing information that is as detailed as possible
2. Justification- Provide appropriate justification for why you are recommending a certain course of treatment. Be sure to explain why something less costly (intensive) would not work, and why something more costly was the best option. Then document the reasoning.
3. Code Appropriately– be sure to utilize appropriate coding for care. Up-coding and down-coding can cause serious issues when it comes time for reimbursement, and down-coding never justifies poor documentation
4. Medical Necessity Criteria– make sure that you have documented the appropriate criteria correctly. Always double check that the duration and intensity of the action plan that you have selected is in line with what is clinically appropriate.
5. Availability- make yourself available to your appointed Physician Advisor should they have any questions about the case, or level of care. Encourage a good working relationship and be ready to provide any additional information that is requested.
