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The use of utilization review nurses to decrease reimbursement denials.

C L Stone, K Krebs

    Home Healthcare Nurse
    |May 1, 1990
    PubMed
    Summary
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    Home health agencies faced more reimbursement denials after new HCFA forms. A utilization review program was developed, successfully reducing both technical and medical claim rejections.

    Area of Science:

    • Healthcare Administration
    • Health Services Research

    Background:

    • Implementation of Health Care Financing Administration (HCFA) forms 484, 486, and 487.
    • Increased rates of reimbursement denials within the home health industry.

    Purpose of the Study:

    • To assess the impact of a utilization review program on reimbursement denials.
    • To identify strategies for mitigating technical and medical denials in home health.

    Main Methods:

    • Development and implementation of a comprehensive utilization review program.
    • Analysis of denial rates before and after program implementation.

    Main Results:

    • Significant reduction in technical denials.
    • Substantial decrease in medical denials.

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  • Overall improvement in reimbursement success rates.

    • Conclusions:

    • A structured utilization review program is effective in reducing home health claim denials.
    • Proactive review processes can enhance financial stability for home health agencies.