Real-World Case 15.1
David, a student from an accredited HIM program, was given a professional practice experience project that
required him to review reimbursement denials for Medicare patients over the course of the past year. He
noticed that the denials were higher when the claim included services from the radiology department. He
researched the claims and resubmitted them with additional documentation. Through this process, he
discovered that the additional documents required were similar for each claim. Also, because of the settings
on the organization’s EHR, the required diagnosis codes for the radiological services performed were not
being submitted on the claim form, although the procedure code was included on the claim. David
communicated his findings to the manager, and they discussed potential next steps.
Real-World Case Discussion Questions
1.
What could cause a denial from an insurance company?
Incorrect or missing information from the patient or healthcare provider. Another form of denial is
because of a pre-existing condition. Incorrect or missing coding for a claim can cause a claim to be
denied (diagnosis codes).
2.
Outline suggestions for process improvement to help improve efficiency of the revenue cycle
management.
There needs to be a better way of processing claims through to the insurance company. Electronic
coding and filing will help benefit the company. There were to too much duplicate documentation
needed, codes needed from specific departments, and better staffing training in regard to making less
mistakes with coding and documentation.
3.
Which departments are responsible for the revenue cycle problems at this company?
The radiology department had missing codes and needed additional documentation to go with the
claims that had been previously submitted.
