Do the payer’s credentials match or exceed the clinician’s credentials
Dr. Wilbur Lo, Chief Medical and CDI Officer for cdiWorks, addresses the critical need for a strong denials’ management team and the role of physicians to be an active participant on the CDI team. Dr. Lo writing for ICD10Monitor notes, “facilities should retain a team of physicians who can review the cases and generate clinically robust appeal letters that adhere to the Official Guidelines for Coding and Reporting for ICD-10-CM/PCS and Coding Clinic.”
Dr. Lo also addresses the role of non-clinicians in the reimbursement decision-making function. Specifically, third-party payers’ policy allowing non-cliniciansto render final decisions for payment or denial of claims – that is, approval or denial of payment for a service provided by a licensed clinician. While some non-clinicians have extensive medical knowledge and can participate in medical-making decisions, one must question how our healthcare payment process has developed to one that allows a non-clinician’s decision to take precedence over a clinician decision? (Clinician – an individual with education and delivery of patient care to sit (and pass) a board license)?
Payers—who represents you in the reimbursement decision
Dr Lo’s presentation on Talk Ten Tuesdays’ broadcast, February 4, 2020 also urged the healthcare industry – specifically providers – to require third-party payers to disclose the name and credentials of the person rendering the denial, or, reduction in payment category (DRG). Being a clinician and a coder (AHIMA certifications) with payer experience, I relate to Dr. Lo’s call for disclosure of the person making the claim’s payment decision. With extensive knowledge of the claims’ adjudication process, I am passionate about the responsibility and accountability of the payer’s decision-making.
While I disagree with Dr. Lo that the payer should disclose the name of the individual rendering the denial, as this has too many options for retaliation and misconduct, I do agree the credentials of the payer’s decision-maker should be disclosed in the denial letter. Licensure and certifications of the individual(s) should be provided to the clinician and provider. Not only the clinician, but also the patient, deserve to know the payers decision-making process, the denial logic and the credibility of the person making the denial.
As many in the healthcare adjudication process are learning, the credentials of the payer’s decision-maker are few and may not be current with industry technology, practice and standards.
Healthcare reimbursement has become too complex and complicated, with the potential to impact other factors – risk, quality, reporting – for the payer not to be engaged on the same professional accountability level as the clinician. The standards that apply for the provider should apply to the payer. The credentials of the clinical staff – MD, RN, certifications: CDI, ICD-10, CPT coding, CAHIMS, should be required of the payer’s staff. The same or comparable credentials allows for the payer to render decisions respectful of the clinician – their education and delivery of care expertise.
Industry Standards
Do industry standards exist for the payers’ medical staff? Are healthcare payers’ required to employ clinicians with current medical knowledge; how many; what specialty? How does a clinician (or non-clinician) working in the payer space stay current with medical conditions and diseases, procedures, technology, industry guidelines and federal regulations that impact the delivery of care?
Does our current industry standards allow each payer to develop their own qualifications to perform in the Medical Payment / Denial function?
Comments