The threat of medical necessity denials of coverage – a mainstay of insurers to avoid paying claims – requires providers to have administratively costly utilization management (UM) departments. Good physician documentation and educated UM processes are highly effective in getting such denials overturned.  

However, there are also so-called “technical denials,” in which real or alleged provider lapses in the prior authorization process arise that can be hard, or even impossible, to overcome.  During the next live edition of Monitor Mondays, Marvin Mitchell, director of case management and social services at San Gorgonio Memorial Hospital in Banning, Calif., will report on this emerging audit trap, and also discuss how to avoid or overcome these crafty insurer maneuvers.

Other segments reported by an array of trusted subject matter experts will include the following:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs). 
•  Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
•  Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment. 
•  Legislative Update: Cate Brantley, legislative analyst for Zelis, will report on current healthcare legislation.
•  SDoH Report: Lenel James, business lead for the Blue Cross Blue Shield Association, will report on the news that’s happening at the intersection of healthcare regulations and the social determinants of health (SDoH). Mr. James will be substituting for Tiffany Ferguson.