Can Only a Clinician Perform Clinical Validation?

There has been a kerfuffle on LinkedIn I would like to expound upon today. A colleague of mine, Siraj Khatib, was recently expressing his exasperation at clinical validation audits.

He referred to the Recovery Audit Program Statement of Work (SOW). In 2011, there was a paragraph in the section titled DRG Validation vs. Clinical Validation, which read, “clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials.”

Dr. Khatib went on to posit that “only a bedside clinician is able to understand, interpret, (and) judge a patient’s clinical condition,” and pondered how “a medical director can have clinical acumen … (having) relinquished bedside medical practice for the comfort of an office, awaiting a bonus to churn out denials.”

There is a lot to unpack here.

First, I would like to validate the frustration of incurring unfounded denials. It requires a great deal of time, effort, and money to combat denials. Sometimes, there is legitimacy – the medicine is questionable, or the documentation is weak. Often, it is infuriating – the medicine is solid, the documentation impeccable, and the insurer is just throwing spaghetti against the wall to see what sticks.

Who is qualified to perform clinical validation, determining if a patient possesses a condition that is documented? The only one who truly can perform clinical validation is a clinician who is taking care of the patient. Did the patient have an exacerbation of their chronic systolic heart failure or not?

However, that is not how the system works. People who are not responsible for the patient’s medical care review the documentation and must make determinations based on the way the encounter is portrayed in the medical record. That is referred to as “clinical validation.”

Who is sufficiently competent to perform this role? The 2011 SOW expressed the decision of the Centers for Medicare & Medicaid Services (CMS) that they were going to only permit clinicians to make clinical validation determinations. I have always asserted that their decision to only utilize clinicians, such as nurses or physicians, is not a universal mandate. It was the stated practice of CMS.

Two of the best clinical documentation integrity specialists (CDISs) I have ever known were non-clinicians, and came from the health information management (HIM) world (you know who you are, Colleen and Kathy!) I do not think it is out of the question that someone from HIM would be capable of doing clinical validation, but I do contend that not all HIM individuals would be able to do so. They need to have experience in the clinical setting and long-term exposure to the medical record. Although clinicians (e.g., nurses, advanced practice practitioners, foreign medical graduates, etc.) are more commonly employed as CDISs, knowledgeable HIM folks are allowed to be CDISs. If they can serve as a CDIS, they can perform the task of clinical validation.

Institutions and systems can make the determination as to whom they deem competent to perform clinical validation. They do not need to insist on clinician credentials. By the same token, commercial payors have the latitude to make this same decision for their organization.

I completely missed the memo about this: in 2017, CMS revised its SOW to read, “clinical validation is prohibited in all RAC (Recovery Audit Contractor) reviews.” CMS no longer specifies that a clinician must perform clinical validation; they say that they are no longer doing it at all. I’m not sure that all the RACs got that memo, either!

But I want to address Siraj’s last contention. When I became a physician advisor for a large multi-hospital system, the system chief medical officer (CMO) advised me to continue practicing clinically. As an obstetrician, he missed operating. I, on the other hand, believed that for the safety of my patients, there was a minimum threshold of hours to remain clinically competent, especially in terms of procedures. If a patient needed an emergency thoracotomy or tracheostomy, I was not the right person for that job. However, I was really good at my non-clinical physician advisor job, despite no longer practicing at the bedside. I am really good at deciphering documentation, and I have 25 years of clinical experience to back it up. I am more than capable of determining medical necessity and quality of care from the medical record, without seeing patients on a daily basis. I suspect that medical directors in insurance companies also have years of experience behind them.

That is not really the fundamental issue.

How people wield their knowledge and generate denials is the problem. Having artificial intelligence (AI) generate a zillion denials in a matter of seconds is a problem. Working on contingency, whereby throwing spaghetti on the wall is profitable, is highly questionable. Rejecting an appeal without weighing its merits is an issue. Having a bonus based on productivity and not on merit is a problem.

One of my superpowers is being able to see things from all sides. I believe the system as it is designed is important, with checks and balances. Providers shouldn’t be able to engage in fraud and abuse, and payors should have to pay for services legitimately rendered without throwing up roadblocks. The government is the biggest payor, and they get their money from me and you. We don’t want them to be squandering our taxpayer dollars, but we don’t want our hospitals to go bankrupt fighting ridiculous denials, either.

If providers deliver excellent medical care and document their thought process well, then payors should pay for medically necessary care of their beneficiaries. If any of these elements is not present, there should be consequences. Clinical validation is one cog in that process, and you don’t have to be an actively practicing practitioner to make that judgment.