I review our IP coding / DRG related denials from a coding perspective. If the coding is accurate based upon coding guidelines and supporting physician documentation, I prepare and submit our rebuttals. I've also begun tracking and reporting trends to other departments within the organization.
I have helped with writing appeals that are DRG-based denials and work with the denials management leadership team. My hope is that our concurrent activities will leave the records "denial-proofed."
Our physician advisors have experience in that area (both coding/documentation as well as UR aspects). Melissa, please feel free to contact me if you'd like to discuss further.
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.
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'm a one person CDI Program and have been asked to start writing clinical appeals. Does any one have or use any templates they would be willing to share?
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!!
I write both clinical validity and coding appeals for our system. We have a small group that manages the process, but I think that we have a pretty good workflow. I provide education to each hospital on problematic documentation that I see during my reviews. In addition, I provide monthly education to both CDI and Coding teams on something related to denials. I have had a lot of positive feedback. I will also concurrently audit charts for CDI where they feel like there may be weaknesses and advise.
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!!
This sounds impressive...where is the 'like' button? I like the fact that 4 MDs review and sign the response, and also that the fee covers all levels of the appeal.
Comments
Don
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
847-982-4212
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.
Thanks, in advance,
Donna
This sounds impressive...where is the 'like' button? I like the fact that 4 MDs review and sign the response, and also that the fee covers all levels of the appeal.