Q&A: Assessing risk for COVID-19 denials

Q: As utilization review case managers, we are often tasked with assessing our hospital's risk for novel coronavirus (COVID-19) denials. What are the most important measures we should be examining?

A: First of all, sufficient physican documentation is needed to ensure that patients will qualify for hospital-level inpatient stay. Even though the risk for denial might seem low because only the sickest of COVID-19 patients are hospitalized, this is still a necessary step.

As physicians focus entirely on handling the crisis and treating patients, you may need to step in and take a proactive stance to ensure denial prevention.

June Stark, RN, BSN, MEd, adjunct professor at Regis College in Weston, Massachusetts suggests that case managers designate staff members to perform real-time chart reviews, identify areas of documentation vulnerability, and work with physicians to improve documentation. In addition, collaboration with the chief medical officer and other physician leaders to support documentation and establish strategies to address insufficient documentation is encouraged. Stark also recommends looking for reasons for technical denials, such as diagnosis-related group (DRG) selection and coding errors. This requires collaboration with coders and the finance department.

Editor's note: This topic was originally addressed in the August issue of Case Management Monthly.