Just the facts: Answering your questions on claim editing and clinical validation

At a recent Cotiviti webinar on claim editing analytics, attendees had many questions about claim editing and clinical validation, a process whereby a team of clinicians, nurses, and coding experts reviews complex, potentially incorrect claims and makes a swift payment recommendation. Here, Cotiviti's Debi Behunin, vice president of clinical performance management, answers those questions.

Do modifier 59 edits require clinical review of documentation, or can they be automated by a claim editing system pre-payment? 

A claim with modifier 59 does not require medical records, but it also can’t be automatically denied. A clinical expert needs to look at that claim to understand what happened clinically to determine what should be paid. Cotiviti uses registered nurses for this work because their clinical experience gives them the ability to look at the claim and claim history and understand what treatment was rendered, and why.


Many payers are really surprised that we can determine whether the use of modifier 59 is justified and should therefore be paid. Cotiviti has developed algorithms that use the information on the claim or in the claim history to determine if the use of the modifier is correct. The diagnosis codes and other procedure codes contain many clues as to how the claim should be paid. 


What type of documentation do you need to perform clinical validation? 

Validating modifier 59 usage isn’t about reviewing a single claim billed with that modifier. We really need to see every claim that’s been presented for that patient, even if we don’t edit those claims, so we can understand how the patient has been treated historically. For example, the presence of an inpatient claim provides many insights into how the outpatient claims should be paid. 


What happens with providers whose contracts exclude them from editing? 

According to our data, payers exclude about 25 percent of providers from the editing process. Cotiviti marks providers as inactive if their contracts stipulate exclusion from the claim editing process. However, we still apply edits to their claims so our clients have information on that population and its billing errors. This information frequently helps payers successfully renegotiate contracts to allow for editing, at least for basic situations such as duplicates or National Correct Coding Initiative edits. 


Only about 10 percent of providers are making billing errors, but those who are cost plans a substantial amount of money. Therefore, conducting a thorough review of provider contracts on a regular basis is essential. Look at the excluded list, re-review your contracts, and point out the potential savings that are lost to your network management team to effect change. Providers are growing more accustomed to accepting basic edits, and those edits represent more than 60 percent of a plan’s potential savings. 


How can new edits be implemented in a way that minimizes provider abrasion? 

The key to effective collaboration with providers to increase payment accuracy is to educate, educate, and educate—not only your provider community but your entire organization. Make sure everyone—from claim operations, to network management, to the representatives answering provider calls—understands how and why you are editing. When you implement new edits, providers will always ask questions. Get in front of those questions by educating your team at all levels. 


After you go live with a new edit, be sure to communicate to the organization the positive impacts you have achieved. This step is important to ensure that edits are not simply reversed due to pressure from providers. Remind your network management team that new edits typically only impact 10 percent of providers. Every change is going to create some noise; you just need to manage that noise by educating all audiences, including providers, about the value of those changes.


Debi Behunin
As vice president of clinical performance, Debi Behunin uses her knowledge of coding and reimbursement within our Payment Accuracy division to help Cotiviti prospects and clients maximize their results. She has more than 30 years of experience editing claims for coding and reimbursement and has been a product manager for a variety of claims editing solutions at Ingenix, GMIS, and Intracorp. She also pioneered the development of state-specific edits for group health, workers compensation, and auto no-fault lines of insurance for several solutions. Debi holds a nursing degree from Wesley Medical Center and is a Certified Professional Coder.

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