Radio Recap: Denial trends and strategies

It seems that there’s a new headline every day related to denials and audits. Not much has changed when it comes to the content of those denials, though, according to Brett Hoggard, MD, chief medical officer of the Brundage Group, based in Tampa, Florida.

“Some of the more common denials we encounter haven’t changed a whole lot in the last couple years,” he said on the September 12, 2018, episode of ACDIS Radio. And, the diagnoses are ones that many CDI specialists could rattle off without even thinking about it: sepsis, malnutrition, acute respiratory failure, encephalopathy, chronic obstructive pulmonary disease (COPD), etc.

One of the major ways to fight these denials is by understanding the clinical criteria the auditor is using to deny the claim, Hoggard says. “We recently had a patient with COPD. The patient clearly had COPD, there was documentation all throughout the medical record,” he said. “But the payer denied because the prescriber didn’t use steroids. So, instead of using traditional clinical criteria, they’re now looking at the physician’s treatment.”

This tactic is particularly concerning “because usually the denier, the auditor, is looking to deny based on clinical criteria, but in this case, they’re actually judging the physician’s choice of treatment for his or her patient and stating that that alone is the reason why COPD was not present,” added Timothy Brundage, MD, CCDS, medical director of the Brundage Group on the episode. “The auditor did not feel that the patient wasn’t treated the way that the auditor would have treated the patient, but they weren’t at the bedside.”

The issues leading to denials may not be solely on the auditor’s shoulders, however. “One of the red flags we’ve run into is when you see physicians cloning notes,” Hoggard said. “That’s a pretty common practice with the electronic health record.”

It can be extremely difficult to defend against a denial and accurately represent the need for the inpatient admission if the notes are the same day in and day out. Insufficient and conflicting documentation—two concerns often in the sights of CDI professionals—also top the list for Hoggard and Brundage. In all three cases, education is the primary mode of correction, they say.

Sometimes, the denials coming in may help direct education after the fact as well. “We’ve seen, in the malnutrition world, that, because of the OIG scrutiny, we’ve actually changed our education a bit to where we ask the doctor to diagnose the condition and document how you addressed it,” said Brundage. “If you look at the federal registrar for what’s required for a secondary diagnosis, that’s not required, but because of how the OIG has scrutinized malnutrition, we have changed our education.”

While there’s clearly work to be done to fight and defend against denials, many CDI professionals feel stretched too thin with their regular work load to be asked to participate in denials prevention or audit work. Plus, when CDI specialists do well in one area, they’re often asked to help with other projects—the monster called “mission creep” —so CDI professionals fear if they assist in this area they’ll have another task to accomplish.

With denials management and appeals, however, Brundage argued the effort gives CDI professionals clearer insight that will help direct their traditional chart reviews and educational efforts.

“I do think CDI specialists need to get involved with denials because it will allow the CDI specialists to know what the auditor is looking for. It will allow them to take that information back when they’re doing their education,” he said. “I do think it is a necessary evil of being a CDI specialist.”

And bringing back that information to the physicians through education can make a huge difference for the organization’s denial trends, Hoggard added.

“When they’re told or shown that their diagnosis was denied, they get frustrated, and are really surprised at just how many things are denied,” he said. “Once the physicians see that, I think you’ll get much more buy in from a CDI perspective.”

Editor’s note: To listen to the complete show from September 12, click here. ACDIS Radio is a free biweekly show. To learn how to register and listen live, click here. To subscribe to the show on Apple Podcasts, click here.