Note from the Instructor: Outdated and mystery payer criteria are real

By Allen Frady, RN-BSN, CCDS, CCS, CRC

Be aware of payer’s “home cooked” clinical criteria which are often not only outdated, but also ridiculous. Contrary to what the payer may claim, a patient does not regularly have to be at a near death state before having achieved grounds for making a clinical diagnosis or meeting medical necessity for simply being admitted.

Physicians are not required to adhere to clinical criteria from the 2000s, 1990s, or 1980s because some semi-retired medical director the insurer hired to review claims/establishing guidelines for the payer hasn’t kept up with the state of modern medical practice.

These sorts of issues have to be dealt with on a contractual and legal basis through the administration and possibly even the legal department.

CDI staff should escalate these clinical concerns. The first step would be in requesting the coverage policies but beware, often the insurance company or payer will initially refuse to provide any sort of policy until a good deal of administrative pressure is applied . Even then, many of those agencies will cite proprietary concerns and still refuse to divulge the policies as they have a financial stake in keeping that information confidential. That stake is financial, and has little to nothing to do with clinical accuracy. The CMS’ Recovery Auditors are one such example of using proprietary magical mystery criteria. As Trey La Charité, MD, FACP, SFHM, CCDS, CCS,  puts it in the book Field Guide to Denial Prevention and Audit Defense:

“Unfortunately, even when facilities produce evidence-based medical literature and consensus-based position papers published by professional medical societies to combat a denial based on a payer’s definition, such agencies often dig their heels in and take the position that they are correct and the appellant is wrong, and that there should be no further discussion.

With this in mind, be aware this type of denial may be stymied only through payer contracting, legal action, arbitration via state-level insurance commissions, and legislative interventions. Ultimately, it may take a combination of all these options to earn some relief from the current onslaught. Although difficult, audit defense teams need to take such actions to take advantage of their CDI programs and to help them in this regard.” (by)

With regard to the recovery auditors, I concede that they do appear to have corrected some of their earlier more egregious transgressions and improved the process a bit. It does appear to me, however, that there is much improvement that still needs to take place.

For further reading on these topics and more, I strongly suggest picking up a copy of the aforementioned CDI Field Guide to Denial Prevention and Audit Defense, reading it cover to cover, and putting the suggested strategies into place at your facility.

Editor’s note: Frady is a CDI education specialist for BLR Healthcare in Middleton, Massachusetts. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement- boot-camp-1.