Self doubt is a necessary part of the process when making claim determinations. As a reviewer, you have the ultimate decision-making authority as to whether a re-opened claim should be denied and the money recouped. You should be asking yourself whether the decision you are making is supported enough to withstand the scrutiny of a multi-stage appeal process.
Some of the questions you ask should include:
- Did I review and apply the relevant policies and regulations?
- Have you researched any precedents and are your determinations made in line with those?
- Did I know enough about the context of the investigation to conduct the review within that context?
- Are the denials substantive in nature?
- Are they denials that will withstand the provider simply providing more documentation during the appeal process?
- Have I provided enough understandable and logical information concerning the reasons behind the denial?
- Will those reasons stand up despite no one defending them?
If the answers to these questions are “yes”, then questioning yourself has done its job and so have you. Clinical review is a difficult but integral part of any program/payment integrity effort. You should approach that work with confidence but always ensure that the work you are performing can stand up to the toughest questions you can ask – because you can be sure that others will be asking them too once those determinations reach the providers.
By Matt Kochanski
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