Navigating Clinical Validation Denials in Medicare Advantage Plans

Safeguard your revenue with effective Medicare Advantage contract negotiation strategies and mitigate financial risks associated with denied claims.

Grappling with the complexities of clinical documentation is not only daunting for clinical documentation improvement (CDI) specialists with traditional fee-for-service Medicare and Medicaid, but now let’s add a subsequent challenge: the specific coding requirements for managed care plans, also known as Medicare Advantage plans. Medicare Advantage plans may deny reimbursement claims based on the contention that clinical findings do not substantiate the coded diagnoses based on internal medical review policies or other “black box” features.

Understanding Clinical Validation Denials

Clinical validation denials are distinct from coding errors as they are not rooted in whether proper coding protocol was followed. Instead, they arise when a payer disagrees with a clinician’s diagnostic conclusion despite the correct coding per ICD-10-CM guidelines. Managing these denials requires a multifaceted approach, blending clinical understanding, coding expertise, and strategic communication with payers.

The financial implications of these denials can be significant, especially given that Medicare Advantage plans often serve a large proportion of the patient population. Therefore, efficiently managing contracts while implementing a strategy to mitigate clinical validation denials is paramount for maintaining revenue integrity.

Strategies for Managing Denials in Medicare Care Advantage Plans

  • Develop a Robust Pre-Bill Review Process

    Implementing a thorough pre-bill review procedure allows for the early identification of potential issues. Clinical documentation improvement (CDI) teams can work alongside coders to ensure the clinical evidence meets payer-specific requirements, thus reducing the risk of post-adjudication denials.

  • Leverage Data Analytics

    Data analytics can be incredibly valuable in anticipating and responding to denials. By analyzing trends and patterns, facilities can identify high-risk cases and payer behaviors, thus proactively addressing issues before claims are submitted.

  • Invest in Education and Training

    Education is the first step to preventing denials. Clinical staff, coders, and documentation specialists need continuous training in defining and documenting medical conditions, particularly those frequently targeted for denials like sepsis, acute respiratory failure, and diabetes. Understanding the clinical criteria that payers scrutinize can help clinicians provide more precise documentation.

  • Foster Interdisciplinary Teamwork

    A collaborative approach between clinical teams, coders, and CDI professionals is critical. Regular interdisciplinary meetings can develop mutual understanding and identify systemic issues contributing to denials, leading to improved documentation and coding practices tailored to satisfy payer expectations.

  • Payer Negotiations

    Medicare Advantage contract negotiations are crucial as they directly influence healthcare providers’ care quality and financial stability. According to KFF.org, since 2023, over 30.8 million out of 60 million people are enrolled in Medicare Advantage plans— these contracts impact a large segment of the Medicare population. Effective contract negotiations ensure that the terms are fair and transparent, facilitating better patient outcomes and optimizing financial reimbursements for healthcare providers.

Some of these recommendations are resource intensive, at which point, consider investing in third-party expertise. Firms specializing in clinical validation denials and Medicare contract negotiations, like KA Consulting, a division of Panacea Healthcare Solutions, can offer critical external insights and support. With experience in addressing and appealing denials, we can help augment an institution’s efforts in combating revenue loss.

For professional assistance and advice on managing clinical validation denials under Medicare Advantage Plans, consider partnering with KA Consulting Services. Contact us today for more information.

About the Author

Marilyn Burgos, MS CDMP – Marketing Manager

Before diving into the world of marketing, Marilyn spent over 15 years working in various roles within the healthcare community. Her extensive experience in the field has provided her with valuable insights and a deep understanding of the industry. In addition, Marilyn’s passion for sharing knowledge led her to coauthor a medical billing and coding book. Follow her on LinkedIn.