Identifying Clinical Validation Denials and Creating Successful Appeal Strategies

Clinical validation denials can be challenging as payers do not always provide accurate, applicable, or sufficient denial rationale. Learn to identify clinical validation denials and how to appeal some common denial rationale.

Learning Outcomes:

• Explain 3 ways to determine if a denial is an inpatient clinical validation denial
• Describe 3 winning strategies for appealing clinical validation denials

Presenter: Karla Hiravi, RN, BSN; Clinical Audit and Appeal Services, Denial Research Group – AppealMasters

Karla is a registered nurse and holds a BSN from the University of Pittsburgh, Johnstown. She has over thirty years of varied experiences in healthcare, including Clinical Documentation Improvement/Integrity (CDI), development of a hospital based denial and appeal program, development of an oncology research program, nurse and physician education, appeal writing, presentations at the Administrative Law Judge (ALJ) level, and direct management of appeals at every level, up to post ALJ appeals. Karla has been with the Denial Research Group – AppealMasters since 2016 and continues to participate in and educate about the medical appeal process.