Providers and patients deserve to have an “expert” on the claim payment | denial button
The claim was coded correctly – after CDI and HIM approval and, after passing all coding edits, the system gave final approval for release of the claim – now, why the Denial?
Often, providers are left “in the dark” as to why a claim is denied and, it may be months later when the denial information is received or known. This begs one to wonder who is in the “ivory claims tower” looking at the claim for the payer. This paper looks at who is in the “ivory claims tower”, their credentials and experience, and suggestions for both payer and provider.
A host of questions one might ask of the payer when the claim is denied:
• Who is the person reviewing and, approving or denying the claim? A physician, a nurse, a non-clinician, or in the current environment – artificial intelligence?
• What level of experience does the clinician have – what are the clinical specialties, how current is the clinical experience, and what is the depth and breathe of clinical knowledge?
• What is the clinicians’ role and experience in the payer environment?
• What are the qualifications of the clinician to perform in the payer environment?
The process
A brief synopsis of the claims process entails an increasing complexity to the adjudication process. Upon arrival of a claim, the claim system will check the individual’s plan and eligibility, the services provided (match of diagnosis and procedure codes), the provider’s eligibility, contracts and regulatory requirements. The claim will system-pay with a pass of all initial system edits; otherwise, the claim stops, and the manual process begins.
The manual review process begins (generally) with a non-clinician’s assessment of the system-identified issue. Although the individual is (often) a non-clinician, the person is experienced in all attributes of claims adjudication. When the issue cannot be resolved at this level, the claim is then routed to a clinician – most often a nurse.
Is the clinician current
Who is the clinician (the nurse) and what are the credentials that qualifies the nurse to perform in the reimbursement arena? Does the nurse have current industry knowledge as well as, familiarity with standards of care, ethical and legal requirements for delivery of care?
The acceleration of change in the world and the impact to healthcare is well documented. The nurse, or clinician, is more likely to be current with industry technology when working in an acute healthcare setting. The same cannot automatically be said for the clinician working in the payer environment. Without exposure to up-to-date devices, procedures and technology, the clinician’s knowledge can easily become out-of-date. So, the question becomes more relevant and valid, “How can the clinician performing in the payer environment possess current knowledge to yield a professional, ethical and legal decision to accurately pay or deny a provider’s claim?
The credentials
First, a look at the person approving submission of the provider’s claim and their credentials. The healthcare industry has many associations, organizations and societies administering and certifying a Health Information Professional’s knowledge of medical conditions and skill to accurately identify and codify the services provided. AHIMA and AAPC are two organizations providing these services with certifications for inpatient, outpatient, CDI (clinical documentation integrity/improvement) and other medical specialties. In other words, the provider must employ individuals with the knowledge and credentials to accurately codify and classify diseases, procedures and all healthcare services.
Secondly, logic would lead itself to ask the same questions of the individual performing in the payer environment – who is the nurse making the decision to reimburse or deny payment for the services provided? Should this individual, representing the payer, be required to obtain and retain current credentials similar to the provider’s representative? As we all know, many rules and guidelines – from CMS as well as multiple health plans and contracts – exist to classify and codify medical conditions, diseases and procedures. As required by governing bodies, providers must meet these credential requirements to accurately submit the claim. Should payers be required to meet the same standards?
Do industry standards exist for the payer’s clinician? That is, knowledge of industry guidelines to classify and codify medical conditions, diseases and procedures? Should standards exist for the payer domain? Or, does each payer develop their own qualifications to perform the Medical Review Payment function?
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