Book excerpt: Build an appeal response team

By Trey La Charité, MD, FACP, SFHM, CCDS

Before the first word of an appeal is ever written, review the denial chart thoroughly with the hospital’s appeal response ream. An appeal response team does not need to be big and certainly should not follow the usual constraints imposed by traditional hospital committee structure.

The team should be small, nimble, and capable of dealing with large swings in denial volumes, as there will be times of feast and famine. While no definitive template exists, at the bare minimum, the appeal response team should consist of two critical and indispensable members: a coding expert and a clinical expert.

Recovery Auditor MS-DRG validation denials are always based on either a coding issue or a medical issue. Therefore, the appeal response team’s nucleus must be composed of people with expertise in these areas.

While other appeal response team members may be helpful depending on the hospital’s circumstances and the Recovery Auditor with which they must contend, the coding and clinical aspects of today’s DRG validation denials cannot be overemphasized.

Editor’s note: This excerpt was taken from the CDI Field Guide to Denial Prevention and Audit Defense by Trey La Charité, MD, FACP, SFHM, CCDS. Join ACDISLive! for an in-depth look at how Catholic Health Services of Long Island (CHS) leverage’s its CDI team for denials management and prevention, on September 6.