One major way organizations can reduce claims denials is to truly focus upon root cause analysis, take a hard look at avoidable unnecessary denials, develop a management action plan and engage in process improvement that holds stakeholders accountable. Case in point, bring into the fold CDI specialists and hospitalists who in some respects to medical necessity & clinical validation denials as well as DRG downcodes. Examine and validate to what extent do hospitalist contribute to these denials due to poor documentation practices, incomplete H & Ps failing to show and describe the true clinical picture as evident in the ER documentation, cut/paste progress notes that say virtually nothing abou
Reality of Clinical Documentation Improvement- Compliance Risk CDI programs have strong potential to significantly raise compliance risks for the hospital or health system in which the program operates. Compliance departments strive to minimize and alleviate the numerous risks associated with the myriad of components associated with and fundamental to the delivery of healthcare. Clinical documentation improvement initiatives can work in tandem, align and collaborate with the compliance department’s goals and objectives, supporting overall efforts to minimize this risk while still achieving optimal enhancement of documentation accuracy, completeness and overall sustainable long-term effective
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CMS under its Medical Review Policy holds its contractors such as the Medicare Administrative Contractors responsible for insuring the payment of provider claims accurately with the primary mission of reducing provider billing errors. The primary goal is to pay the claims correctly the first time around. MACs review clinical documentation to prevent improper payments and choose claims for review based on many factors such as the service specific improper payment rate, data analysis and billing patterns of the provider. In 2014 CMS began a program that combined a review of a sample of claims with education to help reduce errors in the claims submission process. CMS called this medical review
Today’s model of CDI predicated upon retrospective reactive repetitive queries fails to achieve scale and sustainable improvement for a variety of reasons. The biggest obstacle to achieving true documentation improvement over time as individual hospital programs mature is the current system is not designed or intended to positively affect any patterns of documentation beyond diagnoses typically appearing in the chart 24 to 48 hours after admission to the hospital. What’s wrong with this approach to CDI? First, by definition it is retrospective in nature. Often, the query is soliciting the inclusion of a diagnosis in the assessment that is no longer supported by the clinical indicators, clini
