Q&A: Strategies to address post-payment audits and denials

Q: We are experiencing post-payment audits that result in denials of inpatient claims. Our coders and CDI leaders are vehement that the patient meets MCG and/or coding guidelines, but the payer is using clinical results from the patient as their justification. It seems as if they are ignoring all established guidelines. If these are inappropriate denials, how do we fight them?

A: Fight with every tool you have. Do peer-to-peer appeals, and remind the payer they cannot use the retrospective perspective to say, “The patient got better so they never needed to be there.” Give data to your contracting staff so they know what’s being denied—otherwise your contracting staff may not know. Track the number of admissions approved then denied retrospectively and get the contract to prohibit that. Get your contract to specify the rules the payer uses for inpatient status and make the payer stick by them. If it’s a Medicare Advantage (MA) plan, you can advise the patient to complain to 1-800-MEDICARE. That gets action. MA plans hate complaints.

This question was answered on the NAHRI Forums.