I work the DRG denials that are based on the payer challening the clinical validity of the condition, and we do use the information learned in denials to strengthen our charts going foward. Since we do not currently have a dedicated physician advisor, I personally write 100% of the commercial DRG "clinical validity" appeals and also assist the compliance office with denials received through their office from RAC's.
Tricia McGinn, RN
We have a Denials Prevention Management Team in each of the hospitals in my region, and CDI is part of it. This team determine trends and identify solutions to prevent future denials. There is another team that writes the denial letters.
I review the case to see if we can appeal it. If I feel it is strong in our favor I send it to EHR (Executive Health Resource) who along with their coders and physicians take over the appeal. They write a beautiful letter to the insurance company supporting the case both clinically with up-to-date articles/reference material and also coding guidelines/clinics. It is signed by 4 physicians and sent off in a timely manner to the insurance company. We have a portal with them that we upload the chart and other documents for the appeal.The cost for us is just under $300 and this includes all levels of the internal appeal. Well worth the money and time!!