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Decoding payer denials must be conducted and facilitated through the mindset of learning and continuous quality improvement with the deployment of clinically astute staff that embrace the mission of “Proactive Preemptive Denials Avoidance.”
Assessing the real performance of a CDI program using a “Role Based” approach to CDI is instrumental in evaluating the “Real” Return on Investment of any CDI program. This is the first step in identifying transformative processes CDI must embrace and incorporate into current CDI operatives to drive sustainable integrity in physician documentation in support of net patient revenue less prone to denials and costly financial takebacks.
Most hospitals and health systems have invested in Clinical Documentation Improvement Programs in the inpatient setting, now migrating to the outpatient arena. Most recently the professional associations representing the CDI profession have elected to change the name from Clinical Documentation Improvement to Clinical Documentation Integrity. With the name change to Clinical Documentation Integrity, current CDI processes must adapt to actually make headway in achieving real measurable meaningful sustainable integrity in physician documentation that supports both quality of care as well as hospital optimal net patient revenue with preservation. The word “Integrity” in CDI requires CDI to recognize the medical record as a Communication Tool versus a Reimbursement Tool.
Whether by the U.S. Congress or the Mississippi Legislature, there are many rules and regulations in place clearly defining the working relationship between Mississippi healthcare providers and health insurers. But one aspect of the relationship that is unregulated is the issue of what constitutes medically necessary care for purposes of health insurance reimbursement.