Karen Elmore is living in denial(s).

Her job as Senior Clinical Documentation Quality Coordinator for BJC Healthcare involves a daily battle against a never-ending tide: Payers denying diagnoses on the perceived basis of lack of clinical support. Recently she’s had to deal not only with human payers, but artificial intelligence denials as well.

Karen’s organization has worked hard to stem this never ending tide, and found some success with uniform organizational clinical guidelines and consistent education and engagement.

We talk denials, appeals, preventing future denials through provider education, and Kansas City Chiefs football (still undefeated as of publish date), on this episode of Off the Record.

On this show we cover:

• Karen’s unique role as program manager for CDI at BJC, including responsibilities for physician education, engagement, and denials prevention

• Typical denials for sepsis, respiratory failure, and malnutrition: What payers are using for ammunition

• What payers are the worst offenders, and particularly creative (and egregious) tactics

• AI denials—how do you spot them, and combat a machine?

• Provider engagement strategies and relaying denials back to physicians

• Legitimate reasons for denial and ongoing documentation shortfalls

• Karen’s Kansas City Chiefs obsession—inside an average Sunday in the Elmore household (it’s crazy)