Your Best Defense Against Denials: DOCUMENTATION

We have been traveling on a journey through the very frustrating, annoying, and obnoxious world of health insurance company denials. Whether it be a denial for medical necessity, “30-day readmissions,” or accurate diagnoses, it is a waste of time and resources, and it is a barrier to providing the proper care patients deserve. It is good that more attention is being paid to these denials, especially for Medicare Advantage plans, and it is my sincere hope and prayer that these tactics by commercial insurance companies gets reined in.

While it is seems that these denials are random in nature – and many times they really are – and there does not seem to be any way to completely avoid them, there is one strong defense against these denials: our documentation in the medical record.

The only thing that we can do to strengthen our cases against denial is proper documentation. This is especially true when the acuity of the patient may be borderline or – most especially – when the length of stay is relatively short. I interviewed an insurance company medical director, and he told me, “Oh we love those one day stays…” He said that because it is fodder for a denial in payment, and it sets off a lengthy process to get these denials overturned.

We need to document accurately and properly. We need to take the time to document our thinking process, and explain why we are doing what we are doing in the record. At the time we see the patient, it may be self-evident to us. But, when looking at the record months or even years later, it is not self-evident to the person reviewing the chart.

This cannot be overstated. This cannot be overemphasized. Documentation in the record is everything. It establishes the proper diagnoses for the Diagnostic Related Groups (DRGs); it establishes the severity of illness for a specific patient case and hospitalization; it sets the reimbursement for services rendered to care for a patient; and if documentation is poor, it gives powerful ammunition for insurance companies to deny payment. This is not even mentioning the fact that good documentation protects you in medicolegal cases…(that’s another newsletter at some point).

Does this mean that insurers will not deny payment for cases with good documentation? Of course not. At the same time, with good, detailed documentation, it becomes that much easier to defend the care during a Peer-to-Peer discussion; it becomes that much easier to defend the care in an appeal letter; with good documentation, it becomes that much easier to defend the care to an Administrative Law Judge. Good documentation is everything, and poor documentation just makes everything that much more difficult.

Documentation. Documentation. Documentation. It is so so important that we document properly. Yes, we are all busy. And with today’s technology, it is so much easier to document well. In a few seconds, I can document an entire paragraph in the record. It is time very well spent, and in today’s healthcare environment, there really is no excuse for poor documentation.