Many providers have experienced an increase in clinical validation denials. This is a specific denial category that occurs when clinical evidence in the patient chart is inadequate to support a billed diagnosis. It is not the same as coding, billing or charging errors. It is important to understand the cause of these denials and develop strategies to improve the process. For example, if the provider documents Acute Respiratory Failure, the chart should include ABG values, whether the patient has chronic respiratory compromise and evidence of aggressive measures of oxygen intake. Documentation that is lacking in these areas may lead to denial of the claim. Regardless of your setting, it is important to quickly identify these denials and work with your providers to adequately support conditions documented in the record.

Webinar’s Goals:

• Understand clinical validation denials & how to improve
• Review required documentation
• Examples of clinical validation denials & payer disputes
• QIO reviews: What are they looking for?
• Payer & Provider DRG conflicts