How many bites at the apple are audit companies allowed?
I appealed a cross claim denial by Cotiviti back in the beginning of April I just got it back and now they agreed with my appeal, but have come to a new determination to try and change the PDX and down grade the DRG again. How many bites at the apple do they get? This seems to place an undue financial burden on the hospitals/providers. Had they actually looked at the medical record before the first denial they would have seen the original denial was not valid and maybe sent this one. This just doesn't seem right! First, cross claim reviews done by Cotiviti sending denials based on comparing professional billing history with the inpatient bill and denying anything that is not in the patient's history is disgusting we received upwards of 90 at one time had to appeal each one and send medical records with each one because they had not requested medical records yet. They were mailed and by the time they reached us we had maybe a 10 day or less turn around time. So of course we had to fed ex the records because their portal to upload medical records would not work. More cost to our institution. Now 4 months later results are trickling in and they agreed with my appeal and are taking a second bite at the apple? Has anyone dealt with this? Do we have any recourse? 😒
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We just started to see this at my facility and I actually posted here about it yesterday! Looking for appeal verbage if you wouldn't mind sharing.
Hi Stacey,
We have just started our Clinical Coding Denials Department in March with designated specialists devoted to just denials. I am more than happy to share any information and insights I may have but just putting this out there that I am very new to this arena. Not new to CDI or nursing lol.
I reached out to an incredible speaker I met at ACDIS conference who specializes in denials and she said that they can do this.
Just another way for the auditing companies to overwhelm providers/health care systems. Yesterday I received a cross claim review for a newborn chart want to remove a congenital code because after they compared the submitted claim with professional claims. How would a newborn chart even have a professional claim to compare it to?!? This is a chart from this year i believe 7/2025. It was for Q22.1. congenital pulmonary valve stenosis in a NICU chart. There were serial echos , the documentation was present, and cardiology consult as well as numerous other monitoring and interventions. It was a 48 day stay in the NICU. APR DRG case --> it was a Illinois Medicaid Case so I am thinking they may be a recourse for me to reach out because this denial of the claim before seeing a chart is so egregious and is just noncompliant audit practice. I do have list of references that I am using to support my arguments of non-compliant practices of this auditing company's audits. If you would like me to email you what I have just contact me via email I will be more than happy to share what i have.
I do have to say when we attacked those cross claim reviews and appealed every last one of them --> there has been a significant decrease in the amount of cross claim reviews. Since that period of time I may have received 2 cross claim reviews.
I am also looking into further recourse we have as providers and maybe starting some kind of advocacy campaign to lobby against some of these non-compliant audit practices. We may not be able to do much with commercial payers but medicare advantage and medicaid I believe there has to be some recourse.
Respectfully,
Shannon
Shannon.DiSilvestro@uchicagomedicine.org