Monitor Mondays

Many hospitals are seeing increasing numbers of significant payment reductions that are the result of so-called “forensic” or other reviews conducted by third-party auditors. These are done on outlier claims, particularly for Medicaid HMO claims, as well as commercial and even Medicare Advantage claims.The denials are for commonly billed services and items such as supplies, IV solutions, point-of-care (POC) labs, venipuncture, respiratory therapy services, etc. The rationale given for the denials is that the charges are “unbundled” and should be included in a room rate or a procedure charge, or labeled “routine,” and thus not separately billable or payable.Appeals are reported to be very time-consuming, with no guarantees of success. Reporting our lead story during this edition of Monitor Mondays will be Amanda Gilliland, a revenue integrity nurse auditor at UW Health in Madison, Wisc. Gilliland reports on her experience and efforts to appeal what she describes as “spurious” denials. The broadcast rundown als