BHM’s reporting package for peer review/physician advisor services allows on-demand drill down on each LOC, as well as, many other variables.
At times, physicians are dubious of these reviews because they feel that those who are auditing the charts may not have the right kind of medical training to truly understand the nuances of the chart. This is a valid concern. It’s up to the payers undertaking the audits to prove that those reviewing the charts are fully trained and capable to review the chart and that they will fairly and accurately assess the chart. If, in fact, their assumptions were wrong then they will agree that the care was correct at the inpatient level – but, by allowing them to deeply audit the chart, the payer and the physician can both be assured that the amount paid for the services is accurate.
Now, what in a chart would make a payer question the validity of a claim? Sometimes, it’s simply based on something that they couldn’t intuit from the chart where there was seemingly a gap in physician documentation. Often, expert medical coders will catch this and can refer it back to the physician before the chart is coded. If they are able to catch these things before the claim is submitted, it will reduce the time and money spent on denials.
Other times, the problem may be with the coding itself. It’s always possible that a coder made an honest mistake with a code, but with the advent of new computer assisted coding and the megalith of ICD-10. There are times when a coder might code to what they think is the highest diagnosis and perhaps the insurer doesn’t agree. This miscommunication can be resolved, but it’s frustrating for both parties – and the physicians, who come to think that there is something amiss with the hospital’s coding department.
Researchers at ReviveHealth and Catalyst Healthcare Research developed a unique testing model to measure trust in business-to-business relationships. In 2016, 143 hospital executives and 602 practicing physicians participated in the survey. For the first time, the research firms also extended the survey to 74 health plan executives. One finding was business-to-business trust levels in the healthcare industry rank among the lowest of all industries in the U.S. This may explain why the transition to value-based care delivery is crawling at a snail’s pace.
When everyone’s faith in one another is undermined, it creates a difficult situation for resolving conflict and making sure that everyone is doing their part to reduce denials. Hospitals and physician groups think that payers are the enemy, payers are just trying to keep everyone honest and, of course, make money for themselves, and the coders are the monkeys-in-the-middle who regularly vacillate between hating the physicians for having sloppy documentation and hating the payers for being cool and disinterested in the nuances of their unique patient demographic.
Using Medical Necessity Criteria (MNC) successfully requires constant attention, understanding, and on-going education. BHM’s reviewer network MNC expertise allows you to focus on patient care. Click HERE and discuss how BHM’s MNC expertise can overcome medical necessity criteria challenges and improve your metrics.