Rev Cycle Rockstars

DENIED & CONFUSED

100

This denial occurs when the payer identifies another insurance company that should have been billed first.

COB Denial

200

For all payers on accounts with dates of service prior to June. Before escalating any drug-related denial to JOC or taking further action on the denial what must you do?

Required Steps:

1. Review the denial and claim details.
2. Verify that the appropriate JZ/JW modifier has been appended to all applicable high-cost drugs under Revenue Code 636.
3. If a modifier is missing or incorrect escalate to CDM.
4. Only after completing this review should the account be escalated to JOC, if further assistance is required.

300

An inpatient claim may receive this denial when the payer determines the patient should have been treated under observation status instead.

Level of Care Denial

400

This denial occurs when the payer determines the procedure was performed in an outpatient setting when a less costly setting would have been appropriate.

Site-Of-Service Denial

500

A Medical Necessity denial can also mean?

No Authorization

TAKE ME BACK

100

This colorful cube puzzle had kids and adults twisting and turning for hours trying to match all six sides.

Rubik's Cube

200

In the 1980s, these became a fashion craze thanks to aerobics classes and movies like Flashdance.

Leg Warmers

300

The slogan "I've fallen, and I can't get up!" made this medical alert commercial famous in the late 1980s.

Life Alert

400

Kids in the 1980s couldn't get enough of these small, colorful creatures with wild hair that came in many different varieties.

Trolls 

500

This teen sitcom starred Will Smith as a street-smart teenager from Philadelphia who moved in with his wealthy relatives in Bel-Air.

The Fresh Prince of Bel-Air

NAME THAT THROWBACK

100

Who did Michael Jackson say he wanted to love in this 1982 hit?

Pretty Young Thing (PYT)

200

What did Kelis say brings all the boys to the yard in this 2003 song?

Milkshake

300

Where can you find 50 Cent (The rapper)?

In Da Club

400

This 1991 dance hit by Crystal Waters features the memorable lyric, "La da dee, la dee da," and tells the story of a free-spirited woman living life on her own terms.

Gypsy Woman

500

This 1978 hit song by The Police tells the story of a man hopelessly in love with a woman whose name is repeated throughout the chorus.

Roxanne

LyRiC mE tHiS

100

How many Chambers did Wu-Tang Clan want you to enter?

36

200

In a famous 1967 Jimi Hendrix song, he asks permission to stand next to this.

"Your Fire" 

300

Dr. Dre & Snoop Dogg said "Ain't nuthin' but a what?

"Ain't nuthin but a "G" Thang."

400

What did Wu-Tang tell you to protect?

Protect your neck

500

What state did Dr. Dre & 2Pac say knows how to party in this 1995 song?

California

AUTHORIZED & DANGEROUS

100

What should you do when you get a 197 denial?

1. Check if an authorization was obtained.
2. If an authorization is on file, verify that it is valid for the services billed.
3. If no authorization is found:
   • Contact the insurance company to determine the appropriate authorization vendor.
   • Contact the authorization vendor to confirm whether authorization was required and whether one exists on file.
4. If authorization was required and no authorization was obtained:
   • Submit a RIRV No Authorization Appeal or RTDA for Inpatient appeal
5. If a valid authorization was obtained:
   • Push back to the payer by submitting a reconsideration/claim dispute/reprocess and include the authorization documentation as support.

200

An authorization denial was received for an outpatient CT scan. The authorization number on file is valid, but it was approved for a different CPT code than the one billed. What should you do first?

Verify whether the billed CPT code should be corrected or if a retroactive authorization update can be obtained?

300

If a service has been authorized, is the insurance obligated to pay?

NO! 

An approved authorization DOES NOT guarantee reimbursement from the insurance company.

400

What needs to be included in your Invision note when you find an authorization?

• Authorization vendor name
• Where the authorization was located or not
• Vendor phone number (if applicable)
• HCPCS, CPT, and DX codes
• Approved dose and frequency
• Number of approved visits
• Total approved billable units
• Authorization number
• Authorization effective dates
• Whether the authorization was approved or denied

500

Before appealing a no-authorization denial, what is the first thing you should confirm?

Whether the service actually required authorization

ADMIN 101

100

How many days can you be out, before having to provide a Doctors note?

5

200

You get an email from a Supervisor informing you of an update to a current process.  What should you do?

All staff are expected to reply to the email, acknowledging receipt and confirming their understanding.