CDI Week 2019 Q&A: CDI and denials management

CDI Blog - Volume 12, Issue 119


Shirlivia Parker, MHA,
RHIA, BS, CDIP

As part of the ninth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Shirlivia Parker, MHA, RHIA, BS, CDIP, senior manager of physician partnerships/education and advocacy and an interim CDI physician educator at Providence St. Joseph Health, and a member of the 2019 CDI Week Committee, answered these questions. Contact her at shirliviaparker@stjoe.org.

Q: According to the 2019 CDI Week Industry Survey, 56.51% of respondents are currently involved in the denials management or appeals process. Is your CDI team involved in this process? When did they first get involved?
A: Yes, our CDI team is involved, specifically with clinical validation denials. We currently have a full-time employee as our CDI denials coordinator on the St. Joseph legacy branch of our organization, who oversees two regions, Northern and Orange County California. In all other ministries, CDI team members are involved to support the process.

I initially got involved with claims denial, specifically with clinical validation denials, in November of 2017 for the northern California region. We hired someone for me to mentor and train for our denials coordinator position April 2018. From there we expanded to Orange County in January/February 2019.

Q: Does your CDI team help with all types of denials or just a particular subset?
A: The initial goal of CDI involvement with denials was specifically to assist with clinical validation denials, which targeted inpatient claims. However, in 2019, we have branched out to some outpatient denials as well.

Initially we decided to help out with inpatient denials only, specifically clinical validation denials, because the essence of what CDI does on a day-to-day basis is review claims for clinical evidence to validate a diagnosis. 

Clinical validation denials (and appeals) require both a clinically astute mind and an advanced knowledge of DRG methodology. Reconciling records for abnormal findings and determining if the treatment rendered supports a given diagnosis are inherent to the role of CDI.

As a result, CDI was the perfect choice in my opinion to lead the charge on clinical validation denials.

Q: Who on the CDI team is involved with the denials management/appeals process?
A: Our CDI team consists of CDI educators (dedicated to the CDI team), CDI physician educators, managers, and a denials coordinator, and we are all involved in the denials process. The reason we are all involved is to educate our CDI team members on areas for improvement identified through the denials process.

For example, we realized that not all our CDI team members were asking clinical validation queries when appropriate. We involve our CDI physician educators, because documentation and physicians are where the rubber meets the road. We must educate our providers on what clinical validation denials are and help them understand why there is the need to document their medical decision-making process in the medical record for any diagnosis. In the end, a clinical validation denial can be a difference of opinion from one physician to another. However, the medical record can validate the treating physician’s thought process, if documented well. In the end, the treating physician’s documentation can win any denial if done correctly.

Q: Do you have a dedicated team who works on denials? Why or why not?
A: As I mentioned previously, we have a CDI denials coordinator that oversees two regions: Northern and Orange County California.

To ensure system standardization and efficiency, it is ideal to have a dedicated team member under the CDI umbrella or with a dotted line to CDI. This allows utilization of standardized templates for denials and process development that have worked. For example, we realized over time that the following process could streamline the amount of written appeals our CDI team wrote and promote a quicker turnaround time:

  • Step 1: Write the appeal
  • Step 2: If still denied, request a peer-to-peer with the third-party company denying the claim on behalf of the payer
    • This peer-to-peer involved the medical director of the third-party company and our CDI physician advisor with our organization
  • Step 3: Finally, if the claim is still denied, request the claim be reviewed by the medical director of the insurance company, as opposed to the third-party company’s medical director

The advantage of this process is that we only had to write one appeal, which eliminated the typical three we were writing before. We won every case that reached step 3. The process developed organically, collaboratively through phone calls between us and the third-party company as it is not stated in any administrative guide for the insurance companies.

Q: How long have you been involved with the denials management/appeals process? How have you seen the denials landscape change over that time period?
A: I have been involved for two years at my current organization. However, I have more than five years of DRG validation denials experiences at my previous organizations.

The denials landscape changed from a focus on DRG-only denials, specific to the Official Guidelines for Coding and Reporting, to clinical validation denials. Clinical validation denials are denials that look at one or more diagnosis documented in the medical record with a review of the clinical findings and treatment to clinically validate the diagnosis as a treated condition/diagnosis during the patient’s hospital stay.

Q: What types of diagnoses do you see most frequently denied? How have you worked to fight against those denials?
A: Sepsis, malnutrition, respiratory failure, encephalopathy, congestive heart failure, and obesity/ body mass index are the ones we’re fighting the most frequently. I am excited to report that we won our sepsis denials using the Sepsis-2 definition (two systemic inflammatory response syndrome criteria plus the underlying infection definition). In addition, we use ASPEN criteria for malnutrition and work with our registered dietitians for their expertise.

Q: What other departments or groups does CDI collaborate with on the denials management/appeals process? In what capacity do they collaborate (e.g., through monthly meetings, during the appeal writing process, etc.)?
A: We work with our physicians, HIM/release of information (ROI), patient financial services (PFS), and coding in the following ways:

  • Physician advisors:
    • On peer-to-peer request.
    • Education and awareness of denials.
    • Template awareness. For example, we learned that all electronic progress notes in our computerized hospital system included canned text of “well-developed” and “well-nourished” within the review of systems general section. After we made our physicians aware of this, they took notice of the text when completing any documentation on malnutrition. This was a huge denials prevention discovery.
  • HIM/ROI:
    • We work with the ROI personnel to ship records with the appeal letter during the denials process.
  • Coding/HIM:
    • Staff provide additional coding insight if needed and typically are a part of the denials process as a whole. They are a great partner to work with through the denials process. It is also a good idea to keep coding informed of the denials landscape with clinical validation denials on the rise.
  • PFS:
    • The PFS representative receives all denial letters and other correspondence. As a result, they start the denials process to ensure the CDI team member receives the denial letter. Any updates regarding payment, etc. come from this team.
  • Contracting:
    • We work with this team to ensure we understand the terms of the contract and any areas we can work on together to improve, such as clinical definitions, time frames, etc.

Q: According to the Industry Survey, 23.71% of respondents have been involved in the denials management process for less than a year. What would you recommend to them as they ramp up their involvement? Is there anything you wish you’d known when you started out? 
A: My recommendation to new individuals in the denials space is to ensure a process is developed to streamline workflow. We work with HIM/ROI to print the needed medical records with the appeal once completed. We work with PFS to receive all initial denials. We work with our physician advisors on peer-to-peer requests. There must be a process in place to ensure CDI writes the appeal but stays out of processes that are another department’s expertise. This will streamline cost for full-time employees involved.  

I wish I would have known the three-step process I mentioned above when I first started in this role. It took me months to discover, and I had to call the entity who denied our appeal three times, with little variation between the first, second, and third appeal letters.

Q: We’ve heard of CDI teams being involved in the payer contracting process to ensure they know all the requirements and clinical indicators set by the payer. Is this a practice you’ve been involved in? Why or why not?
A: Yes, I’ve been involved in the payer contracting process. It’s really important for the contracting team to know what is going on during the denials process. For example, in the beginning of our denials process, I learned from our PFS representative that the company denying our claims was requesting refunds be returned before the denials process was complete. I reported this to contracting, who validated that this process was noncompliant to what was stated in the contract. Ultimately, the third party had to wait until the denials process was completed before taking back any money. Involving contracting in your process is important.

Q: How do you measure the success of CDI’s involvement with this process? What metrics do you track?
A: We track a few different metrics: total revenue secured from appealing the case, overturn rate, our top denied diagnoses, and account details for CDI and physician education.

Q: What effect has CDI had on the denials landscape at your organization?
A: We currently have an overturn rate of 71% in the northern California region where this process originated. This was not the case prior to CDI involvement.

Q: What would be your best piece of advice for writing an effective appeal letter?
A: Ensure you reviewed the denial letter and the clinical references used to deny your claim. This helps you organize your thoughts about what you’re refuting. Upon review of the denial letter, complete any research needed and start writing your letter by summarizing why the claim was denied, and begin your rebuttal referencing the documentation and clinical evidence in the chart.

Q: What can CDI professionals do on the front end to prevent denials on the back end? What can they do even if they don’t work directly with the denials management/appeals process?
A: Educate CDI and providers constantly. Work with other departments too, such as registered dietitians to ensure they are aware of any malnutrition denials.

If CDI is not a part of the denials process, they should focus on clinical validation queries to prevent denials.

Q: Can denials data be leveraged for physician education/engagement? If so, how?
A: Education for providers is a key component of our denials process. We emphasize the importance of adding their medical decision-making thought process in the medical record through documentation.

When we meet with the providers one-on-one, we also review the evidence-based definitions our organization uses. We also discuss all the denials received during physician department meetings and with the specialties it affects. We have found this to be most effective.

Q: For CDI teams looking to get involved in this process, what would you recommend to them as the best first step (e.g., reaching out to a particular person)?
A: I would recommend reaching out to their PFS representative who oversees Medicare Advantage accounts. Medicare Advantage is the top denied insurance type we see. Additionally, reach out to coding and/or the coding quality team, as coding is typically a part of the denials process.

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