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3:25-4:15 p.m.

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Adapting to Commercial Clinical Validation Denials

Commercial payers have shown more and more focus on clinically oriented denials, adapting their reimbursement guidelines to focus on clinical validation to justify denials and, more often, downgrades. Clinical validation represented 90 to 95 percent of coding-related denials hospitals received in 2018. Few payers provide transparency about the clinical criteria they use to assess DRG selection, while others constantly change their criteria.

Even identifying clinical validation denials presents problems. Countering them is challenging, since it requires strong collaboration between coding staff – who hold ultimate responsibility for addressing these denials – and the CDI teams who provide the expertise necessary to successfully appeal.

Presenters at this session will discuss strategies providers can implement to overcome the surge in clinical validation denials and defend their rightful reimbursement. Attendees will receive specific techniques to quantify the extent of their clinical validation challenge and steps to follow to address denials and downgrades that threaten revenue integrity.

Learner Outcomes

Attendees of this session will learn:

• The challenges associated with clinical validation denials.
• Strategies to counter payers' constantly changing DRG criteria guidelines.
• How to educate and align a team on a unified appeal strategy.


Mary Bessinger
Optum360 Phoenix, AZ
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