PP02       Title: Collaborative Quality Project with Utilization Management and Appeals Date: Thursday, June 19, 2008 Time: 12:00 PM - 04:00 PM Type: POSTER Level: ADVANCED Track: - Sponsor(s): - Speaker(s): Mary E Donnelly; Polly K. Howard Johns Hopkins Healthcare LLC provides the managed care infrastructure support and care management for different businesses in the state of Maryland. The financial feasibility of any managed care organization is based on the ability to conrol medical costs. Johns Hopkins Health Care quality improvement efforts prompted the development of a focus audit between 2 departments.  The Denials and Appeals team was originally developed to identify opportunities to improve processes between Utilization Management and Appeals department. The issues that prompted the audit were the inability to align denials and appeals reporting and the sense that Appeals were overturning all denials while Utilization Management was not appropriately documenting reasons for denials.  A comparative analysis was performed to assess both departments’ practices. The study population was selected from one month’s worth of concurrently issued inpatient denials. For each case, the corresponding care management notes, denial letter, and appeals record were pulled for review. Directors of both departments performed an intense review. The results were that divergent reporting was a main issue. The assumptions concerning Appeals and Utilization Management were incorrect. Both departments had opportunities for improvement. A corrective action plan was developed for each area.  A joint corrective action plan addressed areas common to both, for example: criteria and guideline review, the need for specialized inter-rater reliability audits, ongoing meetings with Medical Directors and staff concerning cases, education of denial reasons and appeal practices. Overall the quality study was successful. Objectives: Identify the purpose of this Q& A project by the Denials and Appeals team at Johns Hopkins Health Care.   Differentiate the review findings of original deter¬m¬ina¬tion, appeals determination, and the analysis.   Match the opportunities for improvement with the interventions for each department.