Our facility is beginning to see a trend where a claim is being denied for two different reasons. The claim is originally denied for medical necessity, we appeal the determination, and it is overturned. UHC then performs another review denying the DRG. Any suggestion or advice on how approach this? We are also seeing cases overturned for medical necessity and then a coding or clinical validation denial arrives.

Here are some thoughts:

1. Make the CDS team aware of what is happening. Perhaps they can look to see if their intervention in any of the cases might have made a difference and use that information going forward.
2. Are the clinical validation denials actually valid denials? Querying about the clinical validity of a diagnosis, though difficult to do sometimes, is an important part of the CDS’ job.
3. Some hospitals have CDS’ review all discharge charts prior to billing to make sure that documentation is as strong as possible prior to billing.
4. Discuss the recurring issue with UHC payer representatives and seek clarity on their criteria for both medical necessity and DRG validation. This might help you better tailor your documentation and appeals.
5. Track denial patterns to identify common reasons and adjust your processes accordingly if necessary. This proactive approach might help reduce the frequency of denials and improve your overall claim approval rate.