Avoidable Technical and Clinical Denial Write-Off Management in Hospitals, Physician Offices, and Clinics.

PURPOSE/OBJECTIVES: This article reviews the various types of technical and clinical denials that are usually "written off" and proposes strategies to prevent this loss. For purposes of this writing, avoidable technical and clinical denial write-offs are defined as revenue lost from "first-pass" denials rejections. For example, a procedure that requires an authorization is performed without having had an authorization obtained. After appeals and attempts to recoup the revenue, often unsuccessful, the organization ultimately "writes off" the revenue as not collectable. The question to ask is: Are these claims really not collectable or can actionable steps be taken to conserve these dollars and improve the bottom line? PRIMARY PRACTICE SETTING: Acute care hospitals, physician offices, and clinics. FINDINGS AND CONCLUSIONS: In today's environment, the need to manage costs is ubiquitous. Cost management is on the priority list of all savvy health care executives, even if margins are healthy, revenue is under pressure, and the magnitude of cost reduction needed is greater than what past efforts have achieved. As hospitals and physician clinics prioritize areas for improvement, reduction in lost revenue-especially avoidable lost revenue-should be at the top of the list. Attentively managing claim denial write-offs will significantly reduce lost revenue. IMPLICATIONS FOR CASE MANAGEMENT: There is significant interface between case management and the revenue cycle. Developing core competencies for reducing clinical and technical denials should be a critical imperative in overall cost management strategy. Case managers are well placed to prevent these unnecessary losses through accurate status determination and clinical documentation review. These clinical professionals can also provide insight into work flow and other processes inherent in the preauthorization process.

Interdisciplinary Rounds: The Key to Communication, Collaboration, and Agreement on Plan of Care.

PURPOSE/OBJECTIVES: In the era of Pay for Performance, multiple auditing entities, and shorter length of stays, Interdisciplinary Rounds are the future of hospital care. This article seeks to take a broad look at this tool in its current and historical perspective and examine how it can provide a stable foundation for improved physician-nurse communication, agreement on the plan of care, successful care transitions, and improvements in quality metrics, and reduced length of stay. These rounds reflect the changing attitudes of nurses and physicians toward a more collaborative cooperation, and teamwork, in the delivery of patient care. When supported by strong, visible leadership, they can transform not only direct patient care, but the perception of that care by the patient, families, and caregivers. PRIMARY PRACTICE SETTING: Acute care hospitals. FINDINGS AND CONCLUSIONS: Properly executed, Interdisciplinary Rounds improve communication among the health care team and provide a basis for agreement upon the plan of care. IMPLICATIONS FOR CASE MANAGEMENT: Case management is a logical and frequent choice for a leadership role in Interdisciplinary Rounds. Creating a sustainable culture that drives improved clinical care delivery and reduces readmissions and length of stay requires efforts to ensure clear, concise care transitions. With hospitalist programs and nursing care shifts spanning 12 hr, and several days' off between work days, case management continues to be one of the few constant members of the health care team-often with more knowledge of the episode of care than even the current attending physician. Embracing rounds is a change for the better.