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 Clinical Validation Denial and Appeal Services

Our Approach

 The CBIZ team of RNs and clinical coding specialists are ready to assist your hospital with medical necessity denials and DRG downgrades. Our team’s clinical expertise and payer-based experience provide a keen understanding of the logic behind the denial process and a thorough knowledge of how to appeal and overturn these claims.  Our team can also provide guidance and educational support to address coding issues and clinical documentation. The CBIZ team can assist in the denial process by writing the first and second-level appeals. Our team will provide advocacy and support until final resolution of all appeals.

Medical Necessity Denials:

Today, one out of every five claims is denied. A majority of these denied claims are for lack of medical necessity.  Most often, these claims go unchallenged and for many there are sufficient grounds for appeal.

DRG Downgrades:

Increasingly, payers are downgrading DRG claims, and even using third-party review firms to do so. These third-party auditors are combining DRG and clinical validation approaches and are targeting high-risk CC and CC codes for denials. A successful approach to overturning downgrades must include a medical necessity and coding review.