The Ultimate Playbook for Mastering Claims Denials and Winning Appeals
Clinical Documentation Integrity (CDI)
• CDI professionals are a front-line defense against Clinical Validation Denials. To perform their job effectively, they must possess a thorough understanding of standard, evidence-based clinical definitions. This knowledge is necessary to challenge payor decisions that deny claims based on their own clinical validation criteria. It is known that payors do not always apply clinical validation criteria consistently, which can lead to nonsensical and unjustified claims denials. In addition, CDI professionals can help ensure their organization’s clinical definitions are accurately reflected in the health record and updated with advancing medical science, such as the definition of sepsis. Lastly, CDI professionals must stay informed of those diagnoses at their organizations that are most frequently denied by payors and educate themselves and stakeholders to prevent future denials. • CDI is a valuable partner for Case Management in helping prevent Medical Necessity Denials through their work in assuring that clinical documentation is precise, consistent, thorough, and accurately reflects the patient’s clinical picture.
CDI professionals equip Case Management with the necessary information to justify medical necessity to payors. This collaboration between the two departments is a classic example of symbiosis.
Health Information Management (HIM) Coding Denials , when used strategically, can help healthcare organizations stabilize their revenue. Although it may seem counterintuitive, coding denials are valuable because they provide a roadmap to prevent future denials and minimize revenue loss and write-offs. The first step in the process is to analyze the root causes of coding denials. This analysis helps identify patterns, trends, knowledge gaps, and process inefficiencies. Based on this analysis, solutions can be developed, such as process enhancements and education initiatives to upskill the workforce with industry best practices. Communicate coding denials, appeals outcomes, and financial consequences to the coder of record. This strategy is not intended to be punitive but rather a preventative measure to identify areas that need further education and who would benefit from it. Once denial patterns have been identified, conduct targeted audits on a sample of accounts to better understand the underlying reasons. This enables appropriate measures to be taken to correct the problems identified and prevent future denials. It is worth noting that these audits may reveal that the problem lies with the payors and their unfair denial practices rather than the healthcare organization itself.
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