Q&A: Patient status denials

Q: Our system is seeing increasing cases being denied inpatient care with the suggestion that the cases should have been billed as observation. Right now, our coding department handles the coding-based denials, CDI handles clinical validation denials, and care management handles the status denials. We don’t have any process for CDI and care management to share their denial trends.

How do you handle status denials? Do you have a workflow that includes both the CDI and care management in these discussions?

A: Silos can certainly cause issues. It’s not uncommon for status denials to come through a month or more after discharge. To handle these denials, we’ve formed a dedicated team that specifically works outside of the care management, CDI, and coding teams. This team is essentially our utilization review team and they’re tasked with ensuring clinicals get to the payer, reviewing cases for inpatient criteria, and appealing denials that are supported by medical necessity.

We’re also fortunate to have a physician advisor team that reviews the questionable status denials. We also work to educate providers on the criteria for inpatient admissions. Some facilities have care management in the emergency department to assist with this process because providers aren’t taught the Milliman Care Guidelines and InterQual criteria.

Our CDI team doesn’t own this process, but we’ve been asked to weigh in on documenting medical necessity. Sometimes the medical record isn’t telling a good, clear, accurate story. That is where we can partner with providers.

Editor’s note: Jeanne Johnson, RN, CDI director at Premier Health in Dayton, Ohio, answered this question on the ACDIS Forum. Please note that opinions expressed are those of the author and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries. Find out more about participating in Forum conversations here.