Clinical Validation Denials: Queries and Strategies for Defending Claims

Clinical validation denials are relatively new…and difficult for many of our customers to get their arms around. Hospitals may find clinical validation denials to be especially challenging, due to provider inconsistencies in diagnosing certain conditions, such as sepsis, encephalopathy and myocardial injury. Does your organization use internal definitions to promote compliance? That’s a good start, but payers may not abide by your internal controls, leading to clinical validation denials.

You need a collaborative approach involving all members of the mid-revenue cycle team — including coding, utilization management and clinical documentation integrity (CDI) professionals — to successfully appeal and prevent clinical validation denials. The presenter of this ICD10monitor webcast, Cheryl Ericson, will walk you through key aspects of clinical validation denials, from understanding the complex review process used by CMS, to developing effective queries and strategies that will help you justify admissions and claims data.

Why This Is Relevant:

Clinical validation denials don’t just deprive your organization of revenue — they demand enormous amounts of time and effort from staff who are already overwhelmed. From this ICD10monitor webcast, which will include case examples, you’ll take away a more collaborative approach to effectively defending your claims, saving staff time and ensuring compliant payment for billed services.

Learning Objectives:

• Become familiar with CMS complex medical reviews
• Understand the purpose of organizational definitions
• Recognize the importance of clinical validation queries
• Learn how to defend a valid diagnosis that has been denied
• Be able to translate lessons learned from denials into future CDI efforts

Who Should Attend:

Coding, clinical documentation integrity, utilization management, hospital compliance and denials management leaders and staff; and physician advisors and champions.