Cotiviti and Cross Claim Review Denials
Good Morning,
I am wondering if anyone has had the pleasure of receiving a bundle of "cross claim clinical review" denials from Cotiviti? We have recently discovered over 90 of these claims and found on Cotiviti's website their advertisement of this new "feature" they are boasting about and advertising to perspective clients with a case study. They claim, "this feature allows clinical review to start without the immediate need for medical records and provides a fuller picture of each member's patient journey. Cross-claim clinical review leverages machine learning to follow the patient journey and analyze the claim history related care, helping to catch errors early without sacrificing human expertise". They say it works on their web site, "for claims that our algorithms deem appropriate to review without a medical record, Cotiviti clinical review specialist compare the inpatient admission with professional history to identify diagnosis procedure mismatches. In situations that require further review, Cotiviti will request a medical record and perform a traditional DRG review". What we have found is that they send a denial letter and ask to remove any diagnosis that the patient does not have a history of or have a previous claim with that diagnosis on. They never even requested the medical records for that inpatient encounter! When we send the inpatient appeal letter on the last page it will request the entire medical record. They are denying principal diagnoses as well as secondary diagnoses sending the denial letter via snail mail to multiple different departments with while requesting a 30 day turn around. We should send an appeal along with the entire medical record when they have not even had a human who looked at the current record. They call these "machine learning" determinations. Any one else seeing these? Any particular way you are fighting them?
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