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Review for medical necessity of admission against criteria

Published byBlake Joseph Modified over 6 years ago

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Presentation on theme: "Review for medical necessity of admission against criteria"— Presentation transcript:

1 Review for medical necessity of admission against criteria
Inpatient claim flow Concurrent review by CDI/coder; “working DRG” Service ordered/ provided/ documented Chargemaster Query to and from physician for increased specificity Organization appeals or writes off Coding/DRG assigned Billing/claim scrub/sync up with payer requirements Claim dropped to payer Payer pays/denies all or part of claim Post-payment audit (RAC, MIC, etc.)

2 Service ordered/ provided/documented
Outpatient claim flow Service ordered/ provided/documented Chargemaster Query to and from physician for increased specificity Organization appeals or writes off Coding/DRG assigned Billing/claim scrub/sync up with payer requirements Claim dropped to payer Payer pays/denies all or part of claim Post-payment audit (RAC, MIC, etc.)

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