Question

You are the chief compliance officer for Alabama Medical Center. In your monitoring of the facility's compliance activities, you realize that your organization has a problem with denials for medical necessity. Alabama Medical Center has received 100 denials for medical necessity from Medicare in the past six months. Your staff has reviewed the health records as well as the appeal letters that were submitted to Medicare in response to the denials. You decide to categorize the denials by reason for the medical necessity denial. Your findings on the cause of the denials are presented in Table 5-7.

Of these 100 cases, 56 of the denials were overturned on appeal. There are two physicians that stand out, as they have 25 of the 100 cases. The remainder of the denials come from a variety of physicians. Many different services are represented.

Write a corrective action plan to decrease the number of denials received due to medical necessity.

Compliance is the formal act of obeying an order, rule, or request: It is the job of the inspectors to enforce compliance with the regulations. The company said that it had always acted in compliance with environmental laws.

Medical necessity is a legal concept which refers to the health care services or products provided by a physician to a patient. ... Medicare defines "medical necessity" as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Table 5.7 Cause of Medical Necessity Denials

Medical Necessity Denials
Cause of Medical Necessity Denial	Number of Cases
Inadequate documentation	39
Failure to issue an advanced beneficiary notice	3
Patient admitted to inpatient status rather than observation	9
Lack of Medical Necessity	49

The main problem is the documentation of the problems listed above. The corrective actions should include but not limited to:

1. education - of whom?
2. monitoring of what?
3. training of whom and what?
4. use of what?

In this module

A corrective action plan (CAP) is a step by step plan of action. that is developed to achieve targeted outcomes for resolution. of identified errors in an effort to: - Identify the most cost-effective actions that can be. implemented to correct error causes. I have added a link to an example of a corrective action plan.

• Review the definition of Corrective Action Plan
• Read the Corrective Action Plan (CAP) Process

Answer 1

CORRECTIVE ACTION PLAN : It is a document describe the specific solution to meet goals or to prevent denials.

to decrease denials of medical necessity following action will take place

1. understand why the claims are denied - identification of denial documents and the reason of denials.
2. keep observation management in action - observe the cause of denial , documentation , medical necessity patient status and benificaries
3. tack the process - plan the process education , training provided to staff , prevention of problem
4. identification of problem - identify the cause of problem were the problem occurs and plan the action to be used
5. clear documentation - clear documentation of physician prevent the denials by unnecessary claims
6. train the staff -training programmes has to be conducted to the staff
7. providing reviews - auditing team of action should be done to provide review s and improve the staff consistency
8. data management - data is critical part of any case management programme it prevent the length of stay and improve quality of care

1. educate the staff at health care to accurate the medical necessity and appropriate care guidance

2. need of auditing program to evaluate the staff consistency

3.train the staff regarding case management , utility and in appropriate documentation

4.use of specific and objective criteria - guide the staff in a consistent approach to gather the clinical information by the inter qual review, providing good tools . by this it will helps to p provide appropriate care to the patient.