Winning DRG appeal but getting denied for Clinical Validation

pam.riddle

 Are Medicare/Medicare HMO patients allowed to be reviewed for DRG and if we win that then be reviewed for Clinical Validation?

We are wanting to know of anyone that is having difficulties wnen overturning DRG changes (a WIN on that) but the Auditors then are turning around and denying for Clinical Validation.  Is that legit?  If anyone has had the same difficulties with this we would love to hear from you.  Also if you have any official references that i.e., RAC auditors or other Medicare auditors can't review for other things than the already denied items in the original denial we would love those references. 

RHirsch

You have to separate Medicare from Medicare Advantage. MA plans can do what they want and what you let them do by contract.  MLN Matters SE1521 applies to traditional Medicare and gives rules when MACs and QICs can reopen claims. Get it here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1521.pdf