Denial after claim, but before audit!

We have received a denial letter from this payer and this is the extent of the content:

Our payment to your facility may be different from the bill you submitted. The information pertaining to the claim does not support the derived diagnosis-related group (DRG). Based on the available information, it was determined that a DRG revision is appropriate due to the following reason(s) :

• D62 cannot be validated as relevant to this admission.

The information at the time of review does not support D62 impacted the admission. As a result, the appropriate derived DRG is 700. This may result in a reimbursement that differs from what was expected based on the original claim submission.

The letter did go on to request records so they could determine if the diagnosis was supported. In other words, they denied a diagnosis after getting the claim but before a record audit.

I sent a response explaining why the diagnosis was totally supported, but a second denial came back stating the same thing as above. Has anyone else ever had such an experience. I am trying to be diplomatic, but this is angering me.

Any suggestions on how to handle this would be appreciated. I do not believe we have a contract with them.

Comments

  • I am aware of some insurance companies practicing this way. I have also seen where clinicals were not received by the payor and they use this letter as the first denial. I would ensure that the payor did receive clinicals while the patient was in house. If that is not the issue, I would ask contracting to help you connect with a representative from the insurance company. At this point, you should be able to complete a peer to peer review on the denial and get feedback as to why this has happened. Keep pushing forward until you get answers.

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