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busting myths about clinical claim review

March 16, 2017

We know that automated claim editing is unable to analyze many claims due to their clinical complexity, the most obvious examples being claims with modifiers 25 and 59. These simply pass through the system and get paid without any further intervention. That’s why clinical claim review—also known as clinical validation—is so valuable. Clinical validation is a process whereby a team of clinicians, nurses, and coding experts reviews potentially incorrect claims and makes a swift payment recommendation. Over the years we’ve heard questions and concerns from health plans about the value of clinical validation. Here are four common myths and our responses to set your mind at ease.

myth one: there isn’t much financial value in clinical validation

We’ve heard it before: you already have a primary claim editor in place, perhaps even a secondary editor as well. Why bother with clinical validation? Here’s why: while there is great value in an automated editing system, our experience has shown that clinical validation can consistently catch an additional one to three percent of total claim spending that passes improperly through a plan’s primary claim editing system. When considering billions of dollars in claims, this translates into hundreds of millions of dollars in savings!

myth two: clinical validation requires the patient’s medical record

It’s easy to understand why this myth is pervasive: it’s clinical validation, so you must need a time-consuming review of the medical record, right? Not so fast. The other procedures on the claim with diagnosis codes and claims history can tell you a lot about what’s going on with the patient. For example, let’s say a provider submits a claim with fracture care and repair of a laceration on the same date of service. Claim history indicates the patient is in the emergency room after a motorcycle accident and has suffered a fracture to the right arm and a laceration of the left cheek. In this case, it’s clear that the repair of the laceration is completely unrelated to the care of the fracture and both services are appropriately reported on the claim. The review is then quickly completed without the need to see the medical record.

myth three: we can handle it in-house

We have spent the last 14 years perfecting and refining algorithms, processes, and procedures to accurately and consistently determine whether the provider’s claim has been billed correctly. You would have to make a very large investment to perform clinical validation at the same level as a third-party partner such as Verscend. Not to mention, this investment would distract you from your day-to-day operations.


However, if we still haven’t convinced you, ask yourself these questions: Do you have the financial resources to hire your own team of Registered Nurses and train them as coders? Do you have the resources to the define the policies and rationale to support clinical review of millions of code combinations that are constantly updated? Can you hire enough nurses to cover the broad range of specialties to handle appeals? Do you have the IT resources to create and constantly update payment rules in your system and customize them by provider? You will also need training and quality staff to ensure your clinical validation results are consistent, accurate, and adhere to your policies. Trying to take on such expensive and time-consuming tasks yourself doesn’t make sense when you can partner with someone who already has these extensive resources in place.

myth four: we’ll be overwhelmed by physician appeals when claims are denied

We understand the concern of provider abrasion and the additional work required when a claim denial is appealed, but working with a clinical review partner ensures that you won’t have to handle that burden on your own. At Verscend, when providers appeal our payment recommendations, our specialty nurse coders review the patient’s medical record. If our original payment recommendation stands after further review, we prepare a letter for you to send the provider, pointing to the published rule supporting our edit to give you backup. And of course, the ultimate decision of whether to pay the claim is still yours either way.


Trying to implement end-to-end payment accuracy for your health plan? Check out these best practices you should follow.

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As vice president of clinical performance, Debi Behunin uses her knowledge of coding and reimbursement within our Payment Accuracy division to help Verscend prospects and clients maximize their results. She has more than 30 years of experience editing claims for coding and reimbursement and has been a product manager for a variety of claims editing solutions at Ingenix, GMIS, and Intracorp. She also pioneered the development of state-specific edits for group health, workers compensation, and auto no-fault lines of insurance for several solutions. Debi holds a nursing degree from Wesley Medical Center and is a Certified Professional Coder.

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