Denials/Appeals team

proddy@clarionhospital.org

How many of you are on the denial/appeals team at your facility?  Also, what departments are represented on your committee?  The way it works here: The HIM manager forwards the denial to CDI and the inpatient coder (who is outsourced) and asks for our advisement.  Then, I never hear again whether they chose to appeal, if so, was it overturned, etc.  My coder frequently mentions (when applicable) that if the denials are due to need of clinical validation, they cannot be appealed by coding as they are not coding related.  I understand what she is saying, but I have never been included in anything more than asking me to advise on the denial.  I guess I'm just wondering how it handled at other facilities.  Thanks!

lprescott1

You are bringing up a great point- I had great difficulty getting any information from the denials team- and finally just started showing up at their meetings. I find in my travels this is common at many organizations. I think part of the issue is people don's necessarily understand how CDI can assist with the prevention of denials altogether and of course with the appeals process if they do occur. But we first have to understand which charts are vulnerable and what issues are being challenged to focus our efforts.

Jane.Brown@ensemblehp.com

I was closely involved with reviewing individual clinical denials until earlier this year, and there is a counterpart on the coding side.  Since about April, our denials team, which reports up through Care Management as does CDI, has taken over the reviews.  Our denials coordinator provides monthly feedback to leadership at our UR meeting and a quarterly report that details the diagnoses and procedures denied so that we can be aware.  As a CDI department, we have focused on developing internal guidelines around diagnoses such as malnutrition and acute respiratory failure, that are considered vulnerable from a denials perspective.  This has been led by our Physician Advisor and in cooperation with specialists who often deal with the diagnosis in question.  I definitely see the value in closing the loop.  Trends in denials seem to wax and wane and it's always good to have an awareness of what the auditors are currently targeting. 

mrickman@hcmc-tn.org

jbrown5@ecommunity.com said:

I was closely involved with reviewing individual clinical denials until earlier this year, and there is a counterpart on the coding side.  Since about April, our denials team, which reports up through Care Management as does CDI, has taken over the reviews.  Our denials coordinator provides monthly feedback to leadership at our UR meeting and a quarterly report that details the diagnoses and procedures denied so that we can be aware.  As a CDI department, we have focused on developing internal guidelines around diagnoses such as malnutrition and acute respiratory failure, that are considered vulnerable from a denials perspective.  This has been led by our Physician Advisor and in cooperation with specialists who often deal with the diagnosis in question.  I definitely see the value in closing the loop.  Trends in denials seem to wax and wane and it's always good to have an awareness of what the auditors are currently targeting. 

jbrown5, Thank you for your feedback. 2 questions, 1: You mentioned your denials coordinator provides a monthly report as well as a quarterly report which specifically lists diagnoses and procedures denied...how does the monthly report differ from the quarterly report? Also, not sure how long your Physician Advisor has been in place but, were you familiar with the selection process for an advisor? We are in process of making denials reporting in UR as meaningful as possible and are also considering selecting a Phy. Advisor for our facility. I greatly appreciate your feedback!

kshumpert

We have a small denials team consisting of the HIM director, CDI director, physician advisor, and appeals nurse (me). In our process, the HIM director or her appointee review the coding and documentation.  If there are no coding errors, she will send the denial to me.  I write appeals for both inpatient coding and clinical validation for all hospitals within our system.  I spend a lot of time educating CDI and coding both weekly and monthly.  I submit a concise PowerPoint each Friday to each hospital CDI and coding team regarding one denial and approximately 3-4 questions as it seems to prompt better discussion. We discuss it the following week.  Every other month I discuss a denial trend with examples.  I also share each favorable decision with the CDI teams.  It takes me approximately 30-40 minutes to put together the PowerPoint.   We have received positive feedback from our team on this process.

chwcdi

We have a small CDI team, consisting of 5 specialists. Our CDI director sees all of our denials. She will review the denials. If it is more clinical, she outsources the denial for a CDI specialist to look at. If it is coding related, she sends it to the coder. We then try to find clinical documentation that can back up our diagnosis, if we feel that it really was there. She then sends in the denial. IF we hear back, she presents that at a weekly meeting that we have for our department. There are times we fight a denial and just never hear back, but she always lets us know the outcome if she does hear back on the denial. 

kmhuff80

I am contracted to perform a dual role for the health system I am working for at this time: Clinical Denials Lead CDI & Clinical Documentation Quality Auditor (pre-bill 2nd level CDI & Coding reviews). Clinical Validation Denials currently require about 80% of my time. I report directly to the Executive Director of Documentation Integrity.  We assembled a multi-departmental team to establish an agreed upon workflow process to address Clinical Validation & Coding Denials.
Having everyone on the same page was an absolute necessity. Denials were either being sent to the wrong people/departments or they were being buried on a desk in the business office and going completely unanswered. 
We implemented a workflow this Spring to essentially provide a single point of entry. When ROI, HIM of the Business Office receives a Coding or CV denial it is now immediately logged & scanned into the Business Office portion of the EHR. The denial letter pdf is then forwarded to me. I review the denial letter. If it's a CV denial I notify the designated BO clerk that I will work the denial. If it's a 'straight' coding denial I forward it to the Regional Coding Mgr & notify the BO clerk. Appeal letters flow from me to ROI, and the BO clerk is CC'd on the communication. All decisions are logged in the BO portion of our EHR. 
As for appeal determinations/responses the same workflow and steps are utilized.
This workflow has dramatically streamlined our Denials process. It's unusual now for me not to receive a denial the same business day that ROI or the BO receives it. And it keeps our BO, HIM, CDI, etc teams updated.
I also collaborate with our Physician Educator, CDI Educator and our RD Managers. By sharing denials information with them (why did it occur, what can we do differently) we can work together to prevent denials from occurring. 

tracyaboldt@gmail.com

kmhuff80 said:

I am contracted to perform a dual role for the health system I am working for at this time: Clinical Denials Lead CDI & Clinical Documentation Quality Auditor (pre-bill 2nd level CDI & Coding reviews). Clinical Validation Denials currently require about 80% of my time. I report directly to the Executive Director of Documentation Integrity.  We assembled a multi-departmental team to establish an agreed upon workflow process to address Clinical Validation & Coding Denials.
Having everyone on the same page was an absolute necessity. Denials were either being sent to the wrong people/departments or they were being buried on a desk in the business office and going completely unanswered. 
We implemented a workflow this Spring to essentially provide a single point of entry. When ROI, HIM of the Business Office receives a Coding or CV denial it is now immediately logged & scanned into the Business Office portion of the EHR. The denial letter pdf is then forwarded to me. I review the denial letter. If it's a CV denial I notify the designated BO clerk that I will work the denial. If it's a 'straight' coding denial I forward it to the Regional Coding Mgr & notify the BO clerk. Appeal letters flow from me to ROI, and the BO clerk is CC'd on the communication. All decisions are logged in the BO portion of our EHR. 
As for appeal determinations/responses the same workflow and steps are utilized.
This workflow has dramatically streamlined our Denials process. It's unusual now for me not to receive a denial the same business day that ROI or the BO receives it. And it keeps our BO, HIM, CDI, etc teams updated.
I also collaborate with our Physician Educator, CDI Educator and our RD Managers. By sharing denials information with them (why did it occur, what can we do differently) we can work together to prevent denials from occurring. 

Hello- which EMR do you utilize?  I am interested in the workflow you described with regards to the logging in to the "Business Office portion of the EHR".  Thank you.

psweston

I am a physician with training and experience in CDI, as well as appealing denials for medical necessity and clinical validity.  Im interested in  assisting organizations with clinical validation denial appeals outside of my home institution. Any suggestions on how to go about finding opportunities for this?

teresa.firkins@tjsamson.org

psweston said:

I am a physician with training and experience in CDI, as well as appealing denials for medical necessity and clinical validity.  Im interested in  assisting organizations with clinical validation denial appeals outside of my home institution. Any suggestions on how to go about finding opportunities for this?

teresa.firkins@tjsamson.org

Where are you located please!