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Membership Continuing Education
The Path to Payment: Best Practices for Clinical Denials Management

Publication Date: 12/18/2023


Length: 62 minutes, 14 seconds

Content Level: 1 Intermediate, General CE

Abstract
Medical necessity denials have increased as managed care has taken a large share of the Medicare and Medicaid marketplace. To address the trend, this organization created a clinical denial and appeals program for inpatient hospital admissions, which begins as early as when the patient is hospitalized and continues after an inpatient claim is denied. The Clinical Denial and Appeals (CDA) department, working collaboratively with the Utilization Management and Review department, improved their program by appealing denials within two weeks from the time of referral. Through specialization of clinical staff, expansion of the scope of the clinical appeal, and the assistance of outside resources, CDA realized gains including over 10% improvement with precertification-related denials.

Learning Objectives
1. Describe the increased financial strain placed on hospitals due to current regulatory and reimbursement trends.
2. Develop a comprehensive utilization management and review process to ensure the clinical information supports the patient class.
3. Utilize early intervention processes to overturn denials for faster reimbursement.
4. Identify resources to broaden the scope of clinical appeal.

Speakers:
Emily Jolliff, BSN, RN | Supervisor Clinical Denials and Appeals, Care Management | OSF HealthCare System

Emily Jolliff has 15 years of nursing experience, which includes clinical experience on a cardio-thoracic stepdown unit, and 13 years in case management, predominantly in utilization review and clinical denial and appeals. She also has two years of supervisory experience. In 2022, she was a speaker at the Healthcare Financial Management Association First Illinois Revenue Cycle Spring Conference.

Jennifer Landino, MSN, RN-BC | Director, Utilization Management Review and Clinical Denial and Appeals, Care Management | OSF HealthCare

Jenny Landino holds an MSN degree in nursing leadership and is certified in case management. With 33 years of nursing experience, 26 years in case management and 10 in leadership. She has presented at the EPIC Functional Medicine Conference and the Healthcare Financial Management Association First Illinois Revenue Cycle Spring 2022 Conference.

Keywords: financials, utilization management, appeals

The Path to Payment: Best Practices for Clinical Denials Management

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