Managing DRG Denials
Please share if your CDI team reviews all DRG denials or if your system has criteria that need to be met before addressing a DRG denial. Our CDI team currently reviews each DRG denial. We are considering placing parameters on this work prior to allocating CDI resources for review. Wondering if there are CDI teams that let some denials go based on set parameters such as not meeting a certain dollar threshold. Any details regarding strategies that your system's CDI team has in place for determining resources to allocate to DRG denials review would be greatly appreciated. Thank you in advance for any information shared.
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Hi Elaine,
I have a member of my team that reviews all Clinical Validation denials; this is all she does. When we have time we will review all. If we have more audits than we can get too we triage off those that are requesting recoupment of <$1k. We have also decided not to appeal Sepsis audits if payor is using Sep-3 and is not Medicare or Medicare Advantage, and the pt. does not meet Sep-3. If Medicare or MA we appeal as Medicare does not use Sep-3.
Hi Elaine our hospital actions all denials in-house. It is a multidisciplinary approach and data/findings are reported through weekly steering meetings. Business office takes care of technical denials, coding-DRG Validations (incorrect ICD 10 CM/PCS code). I oversee CDI and Denials team, so we take care of clinical denials (medical necessity) and clinical validations (DRG downgrade due to principal diagnosis, CC/MCC/SOI clinical validity, denials d/t UHDDS not meeting criteria, etc.) We do not have a dollar threshold, and fight all denials. We take denials all the way to ALJ level, and report unjust denials to CMS/DMHC (California). As far as resources, for one hospital we have 2 FTEs working both clinical validations and Clinical appeals, but it will depend on the volume of denials coming. Our expectation is 60-90 min per 1st level appeal, 30-45 min for 2nd/3rd/4th levels..