Coding, Classification & Reimbursement

1.  Filing a complaint on a payer audit/denial

Posted 04-06-2017 09:15
Our facility has been receiving numerous coding audits and denials for which we do not agree with. We always attempt an appeal for these, some of which allow for multiple appeal opportunities. We will supply all the supporting medical record documentation along with Codebook Index direction, Coding Guidelines, Coding Clinics and oftentimes nursing scholarly journals and other reputable information found online. All of this just to be denied after what seems like no regard to the information we supplied. Does anyone know if there is another avenue to take after receiving Final Determinations we do not agree with or is there someone we can file a complaint on these auditors with?

Candice Presley, CCS
Coding Specialist

2.  RE: Filing a complaint on a payer audit/denial

Posted 04-06-2017 09:26

See the post by Alicia Kellogg, we have heard comments about the "contract" issue as well. Now facilities may have to include criteria in their contracts as well. These back and forth efforts to take/receive money seem never ending and just add more bureaucracy and cost to healthcare.


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3.  RE: Filing a complaint on a payer audit/denial

Posted 04-06-2017 10:23
I wonder about contacting your state's insurance commissioner?    I've heard that they can be helpful in cases like this.  

Good Luck!

Jean Uhlenkamp
Clinical Documentation Improvement Specialist
St. Anthony Regional Hospital

4.  RE: Filing a complaint on a payer audit/denial

Posted 04-09-2017 13:39

Great tip on asking the insurance commissioner to get involved.  You may also work with your hospital state association as they can be very influential. 





Cheryl Bowling, RHIT, CCS, CHC, C-CDI

Director Audit and Compliance

Oxford HIM



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5.  RE: Filing a complaint on a payer audit/denial

Posted 04-07-2017 08:26
Hi Candice,

We too have experienced the same type of denial tactics that you are describing.  Most often it involves a review agency for the insurance company, and not the insurance company itself.

For most review agencies, there continues to be fair rules of engagement and their DRG change recommendations are built on solid foundations.

There are a few however, that insist that their clinical requirements be met; even in the advent that physicians with equal or greater specialty certifications and experience, or other expert clinical references as you have stated, are not considered and do not result in a favorable decision response.

In these instances, we will not sign the form of agreement they have sent, and send a letter advising them that we will not agree and that we will take our appeal to the insurance agency directly.

Most payers have their provider appeals process outlined on their websites; and we utilize that mechanism when the refund request or retraction occurs.

Suzanne Drake
Coding Quality and RAC Coordinator
Bon Secours Richmond Health System