Podcast: The insider's guide to clinical appropriateness

When a health plan is deciding whether to pay a claim, there’s no shortage of information to consider and reviews that must be performed, including medical coding and documentation. And perhaps the most challenging question to answer is this: is the information on the claim clinically appropriate? On episode 18 of “From the Trenches” podcast, we speak with Marla Wilson, Cotiviti vice president of clinical and coding operations, and Ken Sabulsky, vice president of audit operations. Listen as they dive into how Cotiviti reviews member claim history and medical charts to ensure clinical appropriateness.

Curious to know more about Cotiviti's unique approach to clinically validating claims before payment? Download our fact sheet and get up to speed.

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Learn more about how Cotiviti Clinical Chart Validation catches higher-value errors that others miss with coding, documentation, and clinical validation.

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About the podcast About our guests


From the Trenches is a healthcare 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 Podcasts, Spotify, Google Podcasts, and many other apps.

marla_wilsonMarla Wilson, CPC, COC oversees Cotiviti’s extensive team of clinical coders and nurse abstractors across all lines of business. Prior to joining the Cotiviti organization in 2004, she held senior management roles focusing on provider reimbursement and education. A clinical coding expert, Marla has also presented extensively at national conferences and seminars. She holds a bachelor’s degree from Utah State University.

ken_sabulskyKen Sabulsky, CCS, RHIA manages Cotiviti’s post-pay audit teams. Prior to joining Cotiviti in 2012, he served in health information management director, compliance officer, and privacy officer roles for several accute care hospitals. He holds an M.B.A. from Saint Joseph’s University and a bachelor’s degree from Temple University.

Podcast transcript

What is clinical appropriateness in the context of a health plan’s payment integrity program, and why is it important?

Marla: Thanks, Jeff. First of all, the important thing to note is really the distinction in coding regulations and clinical audit. Both the clinical validation and the clinical chart validation that Ken's going to be speaking to are really taking into account both coding regulations that are national standards, as well as incorporating that documentation that also supports a clinical scenario. Not really judging medical necessity, but incorporating medical policies and guidelines as well as policies standard across the industry.

Ken: Speaking specifically from a clinical chart validation (CCV) perspective, Jeff, there's several categories of clinical appropriateness reviews that we offer. Our core services center around the DRG and short-stay reviews. Clinical appropriateness from a DRG validation perspective entails verifying that the diagnoses billed—which map to the DRG and inpatient payment category—that those diagnoses billed were supported by the clinical indicators in the records. So for instance, if a patient has pneumonia and pneumonia was billed, does the clinical evidence in that medical record support the fact that the patient truly had that pneumonia? Did the X-Ray support the patient had the pneumonia? Did the other clinical indicators support the patient truly had that pneumonia that was billed?

Clinical appropriateness from a short state perspective entails verifying that the place of service—place of service meaning things like inpatient, emergency room, outpatient observation—we're verifying that the place of service was appropriately assigned and billed based upon nationally recognized guidelines like InterQual and Milliman. The guidelines enable us to map the intensity of the treatment the patient received to that correct clinical setting.

Marla: Let me add on, Jeff, from the clinical validation side, really focusing on payment accuracy from a health plan’s perspective—paying the claim accurately is really our end goal, as well as the health plan's end goal. And on the clinical validation side, coding modifiers play a significant role in determining if, number one, the modifiers have been appended correctly. I just wanted to emphasize that really from a historical perspective, we went back and really did some intense diving into the use of modifiers, and we identified that 38 percent of the time, the overriding modifiers that were appended to claims were not justified. This was substantiated back when the OIG did a nationwide survey and found that modifier 59— which is one of the coding modifiers used to identify if services are appropriately identified on a claim to support the payment aspect of it—the OIG found that the modifier 59 was used incorrectly approximately 40 percent of the time. So that subsequent audit shows that this trend has continued. That's really an expensive cost to the health plan, so our clinical validation process allows us to validate those modifiers.

Ken: I've worked in businesses where there was only a coding and documentation review. There wasn't a clinical appropriateness review. Once we added the clinical appropriateness component, we had more than doubled the prevention rate of incorrect payments. So clinical appropriateness—it's really an invaluable tool used to reduce waste in our healthcare system.

So we've established why clinical appropriateness is important. Moving along then, exactly how do we ensure that claims are clinically appropriate for our clients?

Marla: Well, we use our technology and the human intervention component. We look at situations where an automatic denial cannot be made; this allows us to use the modifiers to identify claims that potentially could be paid incorrectly, and we use the circumstances around the patient encounter and all the services, whether they are additional testing, imaging, other diagnostic services—we use these additional clinical information to help us identify which claims should be routed for what we refer to as a clinical nurse review.

Ken: And, Jeff, speaking from a CCV perspective, really ensuring that claims are clinically appropriate begins with our selection methodology and our selection process, when we identify those claims that look like there could be an issue with the billing. We have a robust library of proprietary concepts, and coupling that with our artificial intelligence and analytics capabilities, they really help us ensure that we're selecting claims that have the highest probability of an inaccurate payment. We have a dedicated and very highly skilled team of medical directors, nurses, data scientists, and medical coding professionals. They work very closely together to monitor the current trends in the industry and build models that enable us to identify those claims that have an incorrect payment with a high rate of precision.

Once a claim is selected, our clinical coders perform an extensive review of the documentation in that record. That review includes not only evaluating what was documented, but it also incorporates reviews of items such as patient labs, imaging, radiology, interventions that really need to be documented to support the diagnoses on the claim. So simultaneously, they apply nationally recognized and proprietary policies to ensure that those diagnoses that were documented and billed were clinically supported—not only documented, but were clinically supported by those critical indicators such as the labs and imaging, etc. We have a very comprehensive review program. It's performed with industry-leading accuracy and audit sustainability rates. And our CCV program this year is on pace to save our clients over $1 billion in incorrect payments. So that's how we ensure that claims are clinically appropriate for our clients.

You both touched on how we use both the technology as well as expert human intervention. What exactly is the role of the advanced technology versus actual humans reviewing the claims and the clinical charts?

Marla: Well, on the clinical validation side, rules are really derived from industry standard, correct coding practices rules and guidelines. Adding that clinical component of experienced nurses who are also trained in coding, we can process the claims still at a rapid pace, allowing the health plan to not slow down on their processing. Only approximately 1 to 3 percent of the claims are actually flagged and routed for nurse review so all the clean claims can be returned immediately. Flagged claims are then validated and returned within a few hours. So that technology, just incorporating a clinical review, still allows for accurate, as well as validated processing through the clinical validation process.

Ken: For CCV, the clinical appropriateness program is supported through the state-of-the-art technology that we have and it's applied by our most valuable resource, which of course is our staff. Technology helps us identify those claims with a high likelihood of having an inappropriate payment based upon certain characteristics on the bill such as the diagnosis codes, the length of stay, the discharge disposition. Artificial intelligence such as machine learning algorithms are applied against the claims data to identify those with the highest probability of incorrect payment versus those that appear to be correct, and which we would not select for review.

Our technology also helps the auditors locate key elements in the record more reliably than if they were just doing a manual review without that technology. Our clinical coders take over once the medical record is submitted by the provider for review. The clinical coders then review the medical record and apply nationally recognized and proprietary clinical guidelines to document if those elements on the bill are supported in the medical records. So our technology and our staff—they work hand in hand. They complement each other very well and together they provide a very thorough and comprehensive review.

What exactly makes a clinician good at reviewing clinical information, both when it comes to reviewing claims and charts? And how do they stay up to date with all the rules and guidelines that we've talked about as well?

Marla: Good question, Jeff. And I think Ken and myself really have similar situations here where we really focus on hiring nurses with a broad range of clinical experience and not just the clinical background, actual nursing experience. Along with extensive amount of coding training, we focus to hire nurses that come with a coding background, but we do have a very extensive robust training program across our organization that allows us to really focus on correct coding, focus on the national guidelines and really giving them the tools to be able to look at all aspects of a claim and situations surrounding the visit. And using that broad range of background in their vast clinical knowledge to apply to each scenario that allows them to appropriately review and return the claim.

What are some notable examples we've seen of clinically inappropriate claims from our team out there actually working in the trenches?

Marla: A scenario from the clinical validation side—and again, we're looking for accurate payment of that claim on a pre-pay standpoint where that claim has been paused for clinical review—a nurse can have a scenario such as a patient presents for, say, a right knee injection. They go into their doctor's office, they have a visit and a joint injection. On the surface, on the claim, it looks correct. Let me reemphasize that really the focus of the clinical validation in this scenario is looking at appropriate use of modifiers, so in this scenario where there's been a visit and a procedure done, the provider would typically append a modifier 25 to the visit code. You have a patient that presents with right knee pain, they give them a joint injection, and on the service that claim looks like it should be paid. However, if you insert the nurse review component, then they can look in the patient's history and previous visits or services to determine if the patient has had a previous visit.

So in this scenario, if the nurse would go into that claim history and see that the patient had been seen a month ago and also had a visit and an injection that was also billed, then the patient basically didn't present for a new problem. This new problem was probably identified on the previous visit and then the evaluation would be inappropriate for this second visit. In that case, the nurse would deny the visit and allow payment for the joint injection. This is a common scenario and the evaluation component of it is really the key here to determine, is this appropriate or not given the scenario and that patient's histories? So many of the edits are removed by the nurses with that clinical experience in providing extensive review of the patient history and really piece together the clinical scenarios that warrant that separate payment recommendation.

Ken: I'll give you a very high level example for CCV. An example would be a patient comes in, they have a medical condition that was precipitated by some type of medical intervention. So, they go to the hospital, they have some type of medical intervention—a procedure, surgery, etc., and a medical condition arises from it. However, that medical condition is a common occurrence in that circumstance. Generally, when you have this type of medical intervention, you will have that medical condition as a result of it, but that condition is asymptomatic. It's not treated. However, it's coded and it's added to the claim. So, there were no services provided for that medical condition. It was expected. No signs or symptoms from the patient—it was not treated, but it was documented and it was billed. That's an example of a clinically inappropriate condition that should not have been billed. I think that gives you a little bit of a flavor for the types of clinical appropriateness reviews that the CCV team performs.

Finally, a provider might listen to this conversation and perhaps think that it sounds like clinical appropriateness review may just be another process to deny a claim so that the health plan does not have to pay it. What's your response to that point of view?

Marla: It's really just the opposite. I've had a lot of experience in this in my prior life. I've been with Cotiviti for over 15 years. I came from really the provider and the health plan side of the business, and it's all about integrity and ensuring correct payment, and really it's around ensuring that we pay the claim correctly. And the number one thing really from the clinical validation side, as I previously mentioned—the clean claims are returned immediately. We're not looking to find all of these claims to deny payment. We're looking for situations that clearly could be inappropriately paid based on the use of the incorrect modifiers. So as I had mentioned, only 1 to 3 percent of the claims are flagged for clinical review, so we're not out there to deny the claim. We're looking for the appropriate claims to pay and those that would require some intervention by a human to be able to assess the clinical scenario, the claims scenario, and the requests for payment for a specific visit to see if it should be correctly paid or not.

Ken: Yeah, and Marla really hit it obviously—we just really want to make sure that the claim is paid accurately. And clinical appropriateness is really a concept that's used to do that, to really ensure that the financial transaction between the health plan and the provider is accurate as it pertains to the conditions treated and the services rendered. It's really just one component of a comprehensive payment integrity program, and it's intended to reduce waste and reduce excessive costs in the healthcare industry. The reviews are supported by nationally recognized healthcare literature, official coding guidelines, and billing guidelines. And quite honestly, I'm very proud to say that I'm part of a team who really strives to ensure that health plans pay and that providers receive the appropriate dollars to support the care provider. So it's definitely not an excuse to a provider's claim; it’s an excuse to get the claim paid correctly. And clinical appropriateness is really necessary to contain those excessive and unjustifiable healthcare costs, and that's what our team does so effectively.



Jeff Robinson
As senior manager of content marketing, Jeff supports Cotiviti's customers by developing a wide range of healthcare communications including blog posts, white papers, case studies, podcasts, and videos. 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. Jeff holds a bachelor’s degree in broadcast journalism from the University of Southern California and an MBA from the University of Utah.

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