Podcast: How clinical validation is good for payers, providers, and patients

When a health plan denies a claim, the provider wants to know why it was denied. Sometimes, the answer is that a modifier appears to have been used inappropriately, which Cotiviti detects using a process we call Clinical Validation. And as we hear from John Neumann, registered nurse and clinical consultant for Cotiviti's Payment Accuracy solutions, Clinical Validation doesn’t just lead to better outcomes for the payer, but also the members and providers that it serves. Listen to the latest episode of Cotiviti's "From the Trenches" podcast.

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About the podcast:


From the Trenches is a new podcast from Cotiviti, a leader in healthcare data analytics, exploring the latest trends in healthcare quality and performance analytics, risk adjustment, payment integrity, and payer-provider collaboration. Check out all our episodes in your browser, or subscribe on your smartphone or tablet with Apple PodcastsTuneInGoogle Play, and Stitcher.


About our guest:


John_NeumannAs a clinical consultant who has spent nearly 20 years in healthcare, John Neumann provides subject matter expertise for Cotiviti’s Payment Accuracy solutions. He works closely with the Cotiviti sales, product, account management and technical integration teams to ensure a smooth transition from sales to implementation, and provides ongoing consultative support. His experience as a registered nurse, certified coder, and cost containment expert bring a unique perspective and proven solutions that have been deployed in organizations ranging from large regional health plans to small third-party administrators. John also served honorably for six years in the United States Marine Corps.

Podcast transcript 

John, let’s start off with a quick recap of what clinical validation is and where it fits into the claim editing process. 

Clinical Validation is a process that generally occurs after traditional claim editing and just before the claim is paid. It leverages historical claims data with targeted analytics and combines clinical and coding expertise. Our advanced analytics have been developed and tuned for more than 15 years and our experienced registered nurses are trained extensively in clinical coding. When a claim is “flagged” for manual review, our nurses are looking at all of the available claim data to determine if the claim has been coded correctly. All of this happens in just a few short hours and prior to claim payment, which greatly improves payment accuracy.


How often does Cotiviti see that an adjudicated claim is still not supposed to be paid as submitted, such as one with inappropriate use of a modifier? 

Well Jeff, to be clear, claim adjudication is a process. Ideally, Clinical Validation happens during the process at or near the end, but before the payment is processed. Only about 3 percent of claims are flagged for review. Approximately 50 percent of those claims that are reviewed are considered “clean” and do not result in a denial. However, for claim lines that are deemed incorrect, the nurse will recommend a denial.


In our extensive experience the majority of these inappropriate cases involve modifier 59 or 25. However, denying a claim just because a modifier 59 is present, is also inappropriate, which is why we have seasoned clinical and coding experts validate these claims.


So let’s say I’m a provider, and my claim was just denied by you, the health plan, because of an improper use of modifier 59, for example. Is this just about saving the health plan money by denying claims? 

That is a great question, Jeff. In my experience, providers and payers tend to focus on denials because of the money. That’s not to say that preventing overpayments is not an important place to focus; it’s just not the only place. In fact, what drew me to clinical coding almost two decades ago, was the ability to improve the accuracy of the patient story; codes tell the story.


I am a clinician, first. If the story is coded accurately, then everyone in the healthcare ecosystem benefits. Accurate data equals more than just accurate payment, it equals better tracking of morbidity, mortality and the procedures and services that drive and determine the best treatments and outcomes; it’s this complex simplicity that many of us thrive on each day at Cotiviti. 


Are providers basically the loser in this scenario of clinical validation, or is there a benefit to them also? 

I just touched on this a little bit. Providers benefit by having accurate claim data. Some providers never see how a claim is coded until they get a denial. When they become better educated, they can help reduce denials and processing refunds for overpayments and spend more time on patient care. There is a cost to the entire ecosystem when claims are inaccurate, and providers stand to benefit greatly by improving their claim accuracy. What we do benefits providers, too. 


You mentioned the healthcare ecosystem and patient story earlier. Are you suggesting that patients benefit from Clinical Validation, too? 

Absolutely, Jeff. Many years ago, I was performing an audit and someone told me that they were using certain diagnosis codes to get claims paid. They were using HIV codes instead of HIV testing codes. The medical “story” of those people was not accurate because of the inaccurate coding. I was shocked and reported my findings.


I have seen my own claims paid incorrectly. At the time, I did not know what clinical validation was; however, I am certain that it would have stopped an incorrect payment. Fortunately, I had already met my deductible and it was not my overpayment (it was the health plan’s), but it could have easily been my money. Moreover, my healthcare data was reported inaccurately.


Clinical validation benefits the entire healthcare ecosystem, including patients. It is not the cure for our broken system; however, it is a precise and proven treatment for some of the fractures we see today. 


We’ve discussed the benefits of clinical validation for the health plan, providers, and patients. Why can’t health plans just perform clinical validation themselves if they want to reap these benefits? 

Well, Jeff, I’ll put it to you this way: if a plan were to have the IT bandwidth, advanced analytics team and experienced clinical support to develop and maintain the national guideline-driven triggers to flag claims for review and route them to a work queue, and if they had the large team of registered nurses, who are also trained as coders—to review the available claim data and history to render a determination and support the appeals process if necessary, then yes, they could perform this themselves. Having come from a health plan myself, I can tell you that the economics of their business operations makes this kind of model unsustainable for most health plans to bring this in-house.


At Cotiviti, we have more than 15 years’ experience with advanced analytics, clinical acumen and coding expertise to support a myriad of scenarios. We also have the processes in place to support appeals, including getting on a call or sitting down with providers to educate them about clinical validation and the value of claim accuracy.  


Health plans can certainly invest the time and money in the infrastructure to build and maintain a clinical validation solution, but I doubt it will ever be a core competency. Cotiviti pioneered clinical validation and we have matured the process for more than a decade.


Podcast music credit: "Inhaling Freedom" by Nazar Rybak, via HookSounds.



Jeff Robinson
As director of marketing communications, Jeff supports Cotiviti's customers by developing a wide range of communications including white papers, case studies, podcasts, articles, and videos offering best practices in healthcare analytics. Before joining the organization in 2016, he worked in journalism as the morning host and news director for KCPW, a public radio station in Salt Lake City.

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