Patient Status Denials
Our health system is seeing many cases that are being denied inpatient care and the suggestion is to bill observation on these cases. At this time Coding does coding denials, CDI is responsible for clinical validation denials and Care Mgmt does the status denials. We do not have any type of process communicating with Care Mgmt about the denials they are seeing. CDI has many concerns regarding this discussion. Some concern our KPI metrics, since theses are happening well after discharge they are messing with our data.
Wondering how other CDI programs are dealing with status denials. Do you have a denial team or do the independent departments handle? What does your workflow look like between CDI and Care Management? Is case status denials a huge issue at your facilities?
We know we need a process overhaul but just aren't sure where to start. Thank you all for your help!
Comments
Hi Angela, great question. Silos can certainly cause issues. In regard to statusing denials, it is not uncommon for these to come through a month or longer after discharge. We have a team that specifically works on this outside of Case management, CDI, and Coding. They are essentially our Utilization Review team and are tasked with ensuring clinicals get to the payer, reviewing cases for inpatient criteria, and also appealing denials that are supported by medical necessity. We are fortunate to have a physician advisor team also review these questionable statusing denials. We also work to educate providers on criteria. Some facilities do have case management in the ED to assist with this process, as providers are not taught MCG and Interqual criteria. The CDI team at my system does not own this process as it is out of our hands. What we have been asked to weigh in on is medical necessity. Sometimes a good story is not being told via the medical record. That is where we can partner with providers. Hope this helps, please let me know if you have any more questions.
Kind Regards,
Jeanne
How do you partner or what steps has your team taken to address and/or review for medical necessity. We currently have a high medical necessity denial situation, and case management is pushing the blame to CDI as missed opportunity without producing evidence.
How does your CDI Team collaborate with CM/UR.