Managing DRG Denials

elaine.koetje@spectrumhealth.orgelaine.koetje@spectrumhealth.org
edited September 23 in 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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Comments

  • cgoeweycgoewey

    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.

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