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 about patient progress or clinical status, problems with progress note situational awareness, rabbit out of the hat diagnostic assessments, discharge summaries that don't "discharge" the patient, inconsistent documentation throughout the chart. As for CDI specialist, consider the volume of queries issued, a Key Performance Indicator for CDI programs, and correlate with the increasing number of clinical validation denials and DRG downcodes. Are we feeding back this information to CDI specialists in the interest of CQI and process improvement? Are the queries clinically valid and is the clinical information and facts of the case supportive of the diagnosis? Are the CDI specialists operating in a vacuum with their blinders on, thinking the query response rate and agreement response rate are right on target for benchmark measurement, not realizing their performance is failing achieving alignment and integration with the revenue cycle? One can make an argument CDI can potentially be negating the effectiveness of the hospital's revenue cycle operations.
It's time to engage in transforming repetitive denials management to a more effective efficient approach of denials avoidance. A reasonable starting point in process improvement is to hold physicians and CDI accountable for relevant denials they have contributed to, requiring a wholesale change to thought processes of documentation and principles of documentation improvement. Denials avoidance requires the awareness and realization that maintaining the status quo is not an acceptable business practice. Process improvement entails investing sufficient resources in root cause analysis and taking the necessary steps to develop a reasonable approach to process improvement that facilitates accountability that is valid, reliable and measurable. KPIs in today's CDI progams are not conducive to supporting and achieving a true denials avoidance culture as relates to affecting positive change in patterns of physician documentation.