Dispute Resolution

Sepsis and Clinical DRG Independent Dispute Resolution Review

An External Appeal/Dispute Resolution Review Service

Sepsis Integrity Review Services provides and independent external appeal/dispute resolution review program to resolve payment disputes between payors and providers for Clinical DRG validation denials and medical necessity.  This program offers a non-biased mechanism for providers and payors to resolve payment disputes involving Clinical Denials for DRG assignment and or medical necessity.  With over 35 years’ experience in utilization review, quality assurance, Education and Clinical DRG validation for MS-DRG/APR-DRG’s. No contract is required.  Providing unbiased convenient as you need flat fee pre-pay,  per each  medical  chart review  application submitted.   Providers and payors mutually agree in business contracts to designate the Sepsis Integrity Review Services as their external appeal/dispute resolution agent. 

 

Common chart reviews for dispute resolution include:

Clinical and DRG Based Dispute Review Services include:

  • Sepsis Clinical DRG validation (DRG Validation for all types of Coding and Clinical Denials)
  • APR-DRG Validation
  • MS-DRG Validation

Medical Necessity Dispute Review Services Include:

  • Length of hospital stay at acute level/sub-acute level
  • Procedure performed in an acute or non-acute setting
  • Readmission within 30 days
  • Device placement
  • Admission to acute level of care
  • Admission to observation level of care
  • Admission to other Exempt Unit (Medical Rehab;Psychiatry;Hospice, etc.).

Overview for the Dispute Resolution Service Process:

 

  • Each Clinical DRG Dispute is reviewed by a Board-Certified Physician, and/or a Certified Coder/Auditor.
  • Each dispute review includes a final summary of findings and the rational for the final determination rendered for each case.
  • Per chart fees are based upon the review of the payer and provider denial and appeal documents, and the review of the medical record documents provided (Applicant is responsible for sending the pertinent documents for the review and rendering of a decision). Length of stay is counted from the day of admit thru and including the day of discharge.
  • The chart review fees must be submitted with the request form and the medical record for review.  
  • Retainer deposits may be arranged for payment if reviews.
  • All dispute reviews are conducted utilizing appropriate/current referencing for nationally recognized medical criteria
  • All DRG dispute reviews are conducted utilizing appropriate/current CMS Official coding and reporting guidelines
  • All Review Experts are  dedicated to providing the unbiased dispute determination that is substantiated by the clinical facts, medical documentation, and the dispute details submitted for the review
  • Clinicians, Certified Sepsis Reviewers, and Revenue Integrity Experts providing the health payment industry with unbiased prompt payment dispute determinations
  • Strict adherence to privacy, security,  and handling of all communications involving PHI/payer/provider and application information