Earlier this month, Intersect’s article “Coding Denial Trends—How to Create an Effective Appeal Strategy” was published in HFMA’s Revenue Cycle Strategist. As our company’s coding appeals manager, I had an opportunity to share information and insights in response to the following question:

As healthcare moves toward value-based payment, what trends are you seeing in coding denials and what strategies are most effective for handling appeals and preventing denials?

Ideally, denial prevention is the ultimate goal. However, claim denials from Medicare, Medicaid, and commercial payers are on the rise. Understanding recent trends in payer denials is critical to creating an effective appeal strategy. Here are three trends to know:  

Coding (DRG) validation versus clinical validation. The difference between coding validation and clinical validation denials is no longer distinct as payers often use a combination of clinical and coding references.

Incorrect review dates. Payers sometimes erroneously reference guidelines effective at the time of review but not in effect at the time of service. The guidelines must be applicable to the date of the claim.

Queries subjected to payer scrutiny. Gaps in documentation may require additional physician query as payers heighten their scrutiny of queries.

Creating an Effective Appeal Strategy

To ensure health systems and medical practices are properly reimbursed and medical claims are handled correctly, we recommend five proven steps to establish a successful appeal strategy:

Ensure communication and collaboration between coding and CDI. Determining the type of denial—clinical validation, DRG validation, or a combination—requires combined expertise.

Create a multidisciplinary approach including senior management in appeals processes. Involve leadership in all critical areas involved in response to denials and audits.

Secure administrative support for tracking denials and monitoring timelines. Appeal coordinators/administrative assistants are invaluable to an effective and efficient appeal process.

Never assume that a denial is correct, especially a commercial denial. Denials are often signed by administrative personnel or staff in the audit department. An appropriate credentialed individual should be involved in the denial.

Provide ongoing education and training. Involve all stakeholdersinperiodic training and provide resources related to denials and appeals.

Even with the best intentions and dedicated staff, denials remain a reality. As healthcare makes the shift to value-based reimbursement, awareness of the latest trends in coding denials is the basis for best practices to avoid denials and successfully manage appeals processes.

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