Diagnosis Guidelines for Dx Validation
Our hospital is a small rural teaching hospital. On my CDI reviews and queries, I was finding that different attending were answering the queries differently depending on whether they were old school or more recent physicians. With the help of my physician advisor and some of our specialist physicians, we developed “Diagnosis Guidelines” for our some of our top queried or problematic diagnoses, and these then were adopted at Medical Staff Meeting. (The physicians did not want to call them policies or definitions, but were comfortable with the verbage of Guidelines).
Recently, I was asked to present the Guidelines to our Casemanagement team. In that discussion, I mentioned that I had heard somewhere along the way that hospitals could potentially use the approved definitions or diagnosis criteria in insurance providers contract negations, etc. The CM manager said that we could not use these for anything related to insurance contract negotiations, because we only had “Guidelines” and not policies. I doubt at this point in time our facility would use them in that manner anyways, but I wanted to get some opinions or guidance on this. Can anyone shed light on whether that is correct?
Comments
:Hi, Allen
This is a 'terrible' question for me to ask, but I will anyway. What can we, in CDI, do in order to obtain the insurance requirements for medical necessity? It occurs to me that unless there is some transparency around such guidelines and clinical indicators used by 3rd parties, our efforts to be accurate and compliant will not be totally effective. I know we have some excellent articles in the association pertaining to management denials, and definitions with key indicators, of course, is a strong component of any CDI team. What frustrates all of us is when we work with those clinical guidelines, only to be told our case did 'not meet criteria'. We are working blind if we can't review the guidelines used by any 3rd party. Thoughts?
Paul
No such thing as a terrible question right? In my limited experience working for the dark side, the Nurse reviewers did in fact have access to those files (or at least we did). Even for the insurance company they were hard to keep up with as every account had different terms, stipulations, coverages, requirements etc. You will have no luck obtaining them from the insurance provider.
This means the only avenue left is to have a physician champion at your respective facilities begin to actively lobby to view the problematic payer contracts and include the CDI team on the relevant findings for documentation improvement etc.
I do not believe an individual CDI will have a great deal of success in gaining access to those contracts, likely because some of the agreed to terms are rather embarrassing for the facility and possibly for the payer. From the payer's side, they likely have financial stake in keeping what they do hidden from what their competitors do...fair enough I guess. Likewise, the facility probably has to sign some form of a non-disclosure with regards to releasing the information for the same reason (to keep the insurance competitors from seeing them). This could narrow the playing field of who the facilities administrators deem worth of "need to know" . It may even be stipulated in the payer contract itself for all I know.
For this reason as I said, I believe a physician champion will have to lead the way in the discussion with administration and or look at it as a true long term lobby effort, as this is not likely to be resolved with a single conversation, email or meeting.
I never knew you worked for the 'dark side'. Anyway, thank you for this response. It is at least helpful to be informed of some of the convolutions imposed upon us by business contracts. Everything we learn, and continue to learn about denials indicates active physician engagement is key to success along with a strong MD Champion.
Thank you!
Paul
Trey La Charite' actually outlines this in his annual ACDIS talk and I believe in his book. It is noteworthy that he once approached the hospital leadership at his facility and had the insurance company put in writing they would no longer use a third party auditor as part of the contract negotiations after that third party auditor denied respiratory failure citing the lack of a Room Air ABG at sea level as the reason for the denial.
I believe physician advisors EVERYWHERE need to follow his lead.
You can certainly follow your internal guideline or policy and still be denied, if the language of the contract specifies that the insurance ruling on the criteria supersedes the Hospital policy (and it would seem many contracts have that bit of unfortunate language...either that or Payers are violating the contract on that front again and again and no one is holding them to it because no one can see the contract).
From a denials management prospective:
I appeal the DRG/Clinical indicator denials. At our last meeting, I asked if we could try to have language added to our contracts that the most recent evidence based guidelines would be the criteria used to support diagnoses. (For example: Sepsis 3, KDIGO).
I routinely appeal denials based on 1960's WHO criteria for malnutrition, 2002 RIFLE criteria for AKI etc.
My VP was interested and we will be meeting with our contracts manager to see if it's possible.
I don't think it will matter if its a policy vs a guideline as long as everyone agrees to the criteria. I would think for med necessity it would be agreeing to Milmen vs Interqual etc.
I'll let you know if we make any progress.
Cynthia