Avoid the Pitfalls of Today’s Denials

In order to understand the current landscape of denials, one must take a look at history. How did we get to a point where rejected claims for coding have become commonplace? Renee’ Krul, a panelist at AHIMA 2020 and co-founder of DRG Claims Management, attributed health plans to running their data and seeing increasing case weights due to specific diagnoses. She sees more payors performing clinical validation through DRG incidence data as one of the culprits for the increase in denials. During the discussion, she stated, “Sepsis and septicemia should be clinical areas of significant clinical focus because of the health consequences of these life-threatening conditions.” As the patient’s file moves through discharge to coding, the focus on sepsis and other infectious and parasitic diseases does not relent. For instance, one payor saw a 40% spike in sepsis related DRG’s which alerted their team to clinical integrity and validation issues. This payor immediately responded and began a sepsis-specific review program to challenge the integrity of sepsis DRG claims presented for payment. The result would have resulted in an increase in sepsis and septicemia related claims’ denials. However, this payor requested additional documentation and explanation prior to payment as a strategy to gain hospital acceptance of the correct DRG assignment.

The claims appeal process is a costly and time-consuming endeavor for providers. According to fellow AHIMA panelist Lorie Mills, Director HIM for Forrest General Hospital, a 473-bed hospital in Hattiesburg, Mississippi recorded 340 coding denials for calendar year 2019, with payor clawbacks ranging from $400 to $86,000. While retaining an outside vendor to write and manage appeals was helpful, it added costs to the claim process. She commented educating the attending physicians is paramount and their CDIs are engaged every day to teach the medical staff. Furthermore, she added, “More providers are requiring physicians to document clinical rationale behind every condition; and, be prepared to defend the position in an audit.” Again, providers often add costly outside consultants to address physician education to comply with an ever-changing landscape of DRG denials.

Another solution to avoiding denials is to protect the case claim prior to billing by having physicians trained in coding review the claim to fact check the clinical details for claim accuracy and completeness. Building on that, Lorie stated, “By having a physician review our inpatient claims before billing the likelihood of being paid in full for the clinical complexity performed is greatly increased.”

FairCode increases clean claim ratios by combining the domain expertise of experienced physicians with modern data science and analytics technologies to increase hospital revenue. FairCode bridges the gap between a hospital’s attending physicians and hospital coders. The result? Patient acuity and Case Mix Index (CMI) are more accurately captured with the correct DRG, and hospital reimbursements adjust accordingly. DRG Validation and physician conducted medical chart reviews happen in real time, significantly impacting hospital quality rankings, and bottom-line results. From clinical validation and chart reviews to payor denial defense, FairCode’s physicians and data scientists are part of a hospital’s coding team. Add FairCode to your existing CDI initiatives and see the difference. Outcomes are measurable and significant. FairCode averages greater than 4:1 Gross Return on Investment.

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