Insurance claim denials can be very difficult to understand and appeal. These adverse determinations adversely affect the profitability of organizations both due to lost revenue and due to the administrative cost of attempting to appeal the denial.
The Beckman Group will analyze your facility's claim denials and determine underlying causes of the determinations. We then work simultaneously to implement processes to avoid future denials while working with you to appropriately appeal those claims that should have been approved and to recover monies owed to your organization. On the front end, this often involves working with your clinical staff to improve documentation and working with your coders to improve initial claim submission. On the back end, this involves working with your appeals team on developing processes for understanding the reason for a denial, obtaining the documentation needed to support the claim and submitting the appeal to receive appropriate reimbursement for provided services.
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During his years as a clinical efficiency consultant and as the Chief Medical Officer of a health insurance company, Dr. Beckman has reviewed thousands of medical records from physician offices and hospitals. He has presented cases to Department of Insurance hearings, has testified in numerous depositions and in the courtroom.
He is an expert in all aspects of clinical decision making and claim processing at health payer organizations. Ken can provide chart review and valuable insight to attorneys handling cases involving insurance claim processing. These include adverse determinations regarding Pre-Existing Conditions, certificate of coverage rescissions and specific policy exclusions.
Actuaries are experts at analyzing data and creating forecasts based on data trends. When that work involves costs associated with the delivery and payment for health care, this work often involves diagnostic and procedure code data sets. Often, trends observed in data analysis have their basis in changes in the way that health care is delivered or changes in coding that caused data shifts. By working with a clinician with expertise in coding and statistical modeling, the actuary can provide a more robust analysis to clients. By incorporating the clinical information into their analysis, the actuary demonstrates to clients a more thorough understanding of both the data trends and the clinical etiology behind those trends.
Although the final version of ICD-10 has not been published, all provider and payer organizations are working to implement transition plans prior to the October 1, 2015 implementation date.
Most work has focused on these organizations rather than on the practicing physicians. In addition to understanding the concepts underlying the new codes, the physicians need to understand the documentation requirements to support the more detailed coding. As a Board Certified Physician with over 12 years on the payer side, Dr. Beckman is uniquely qualified to teach fellow physicians the basics for documentation and coding under ICD-10. We can arrange for onsite presentations at practicing physician groups and to medical staffs in the hospital setting. Please contact The Beckman Group for further information regarding these services.