Why Your Appeal Is Won or Lost Before the Denial Arrives

Decisions about clinical denials are often based on claims submitted before all supporting records are complete. DRG downgrades, clinical validation denials, and medical necessity challenges frequently arise long after the original claim is filed. The outcome of an appeal ultimately hinges on how that incomplete claim is interpreted months later by someone with only the documentation in front of them.

That is why Erica Strick, Senior Vice President of CDI and Clinical Denials at CorroHealth, opens her case for pre-bill CDI with a warning rather than a promise: “I am not going to promise you fewer denials. That is not what a pre-bill program does.” What pre-bill CDI does is decide whether the appeal you will eventually write is winnable, in a narrow window most hospitals never use.

As Strick puts it, “There is a narrow window where the full record exists, and you still control it. That window is the entire program.”

Because she oversees both clinical documentation integrity and clinical denials, Strick sees the same claim twice: once while the documentation is still taking shape, and again when a payer says it isn’t good enough. “In most organizations, those two functions sit under different leaders on different floors, sometimes in different buildings, and they often do not talk to each other,” she says.

The Ending Is the Only Part the Payer Reads

Concurrent CDI remains essential because it improves documentation close to the point of care. Its limitation is timing, not quality.

“Concurrent review made documentation meaningfully better while the patient was still in the hospital bed,” Strick explains. “But look at what’s landing in your denials queue now: DRG downgrades, clinical validation, medical necessity. Nobody is disputing that you delivered good care. The dispute is often how the record reads now that the case is closed. That’s a fundamentally different fight.”

During an inpatient stay, the record is still evolving. Labs are pending. The working diagnosis on Tuesday may not be the diagnosis on Friday. And the final DRG doesn’t exist yet. Strick compares concurrent review to proofreading a novel while the author is still writing the final chapter. “You catch a glimpse of the story, but you can’t possibly tell how it’s going to end,” she adds. “And the ending is the only part the payer reads.”

The full story comes into view after discharge and final coding. For the first time, the complete physician documentation, every consultant note, final labs and imaging, the discharge summary, and the coded DRG exist together, in exactly the form the payer will see.

“So, here’s my question,” Strick highlights. “Record complete, claim not yet released. Who in your organization reads it before it drops? Often the answer I hear is no one. It goes to billing.”

That gap is the entire premise of pre-bill CDI. Concurrent review asks whether the documentation was complete while the patient was admitted. Pre-bill review asks a harder question: if I were the payer’s medical director reviewing this claim tomorrow, would I approve it? The first is about completeness. The second is about defensibility.

The Record Has Two Very Different Audiences

Care teams and payers read the same medical record through different lenses. Clinicians share context because they were there.

A payer reviewer wasn’t. “They have no context, no relationship, and no particular reason to be generous,” Strick notes. “They have a policy document and your documentation.” The record has to carry the argument on its own.

“Hospitals read documentation like caregivers, and payers read documentation like auditors,” Strick says. “We ask, ‘Was the patient sick?’ They ask, ‘Can you prove the patient met the clinical criteria?’ We’re always asking about the patient; they’re always asking about the piece of paper.”

What Makes Clinical Validation Denials ‘Clinically Real and Evidentially Fragile’

The distinction becomes especially important in clinical validation cases. Conditions such as sepsis, acute respiratory failure, malnutrition, acute kidney injury, and encephalopathy are, in Strick’s phrase, “clinically real and evidentially fragile.” The patient had the condition. But a note that says the patient “appeared septic” gives a reviewer nothing to hold on to. What holds up is the lactate, the vitals, the criteria named in the record. “If the criteria you met are not named in the record,” Strick explains, “the payer gets to decide that you didn’t meet it.”

Pre-bill CDI applies a payer-facing lens before submission. The reviewer confirms that coding aligns with the clinical evidence and that the documentation can support the claim under scrutiny. The same review also catches a documented CC or MCC that was never coded. “Coded correctly and clinically defensible are two different standards,” Strick adds. “Pre-bill review is where you check both in a single pass.” You are capturing revenue you might have missed and defending revenue you are about to bill at the same time.

Target the Claims Where DRG Downgrade Exposure Is Highest

The objection Strick hears in every room is the same: we can’t review every chart. “You’re correct,” she notes. “You shouldn’t.” Selection should be targeted and risk-based: high-dollar DRGs, high-denials service lines, high-risk payers, clinical validation diagnoses, and cases where inpatient status is likely to be challenged.

Let Your Denials Inventory Pick the List

“You don’t have to guess at this list,” Strick says. “Your denials inventory already wrote it for you. Pull last year’s clinical denials, sort by volume and by dollars, and the top of the report is your review criteria.”

Over time, selection gets more precise. Rather than a static list someone set in a committee last year, a model can score every claim for the likelihood of denials using the hospital’s own history: which payer, which DRG, which documentation patterns preceded denials. That is what VISION Clinical Validation Technology®, part of the CorroHealth platform does today, so reviewer hours go where the exposure is. “The goal is not volume,” Strick explains. “It’s exposure. The claims where denials would cost the most and be the hardest to argue.”

Who Should Be Doing the Reviewing

Who performs the review matters as much as which claims get reviewed. “This is not a job for coding accuracy alone,” Strick adds. “You need clinical judgment plus denials literacy. Someone who has read an actual DRG downgrade letter and understands how the argument gets made against you.” That skill set is narrow, and the people who have it are usually already deployed on concurrent work, which is why most organizations partner for it. Her advice for vetting any partner: ask who is performing the reviews, whether they have personally worked denials and written appeals, whether there is bench strength to carry your volume consistently, and where the education loops back to where your team lives.

Let Denials Teach the Next Review Cycle

Strick emphasizes that denials data should feed directly back into documentation practice. In many organizations, CDI and denials teams operate separately. “Your denials team is generating intelligence every single day,” she notes. “And in most organizations, it dies quietly in a folder.”

Every appealed case should feed three things: CDI education built on real denials language instead of theory, physician feedback that is case-specific, and documentation priorities that reset every quarter based on what payers are challenging now, not six months ago.

The case-level detail is vital. A physician learns more from a specific example involving a patient and note they recognize than from a broad presentation about documentation standards. And it goes both ways: showing a physician denials that were overturned because of their documentation is as valuable as showing them those that were not.

Strick’s recommendation: “Does your denials team present to your CDI team on a regular cadence? In most organizations, that’s not the case. And if the honest answer to ‘who owns that loop’ is nobody, that’s not a hiring problem. That’s a standing meeting you haven’t scheduled yet.”

Don’t Promise Fewer Denials

Strick is emphatic that leaders define success correctly, “because if you define it wrong, you will eventually kill your own program.” Denial volume is driven by payer strategy and market behavior, things no CDI department controls. “If you promise fewer denials, your program gets judged on a number it does not control, and sooner or later it will lose that judgment in a budget meeting, measured against a number you never should have owned. Quite possibly when you’re not in the room to defend it.”

Strick recommends establishing a baseline before the program begins, a step she says is routinely skipped and without which there is nothing to compare against, then tracking three numbers: appeal overturn rate, the share of appeals rated “strong” at submission, and dollars denied versus dollars upheld. None of these count denials that never happened. All of them measure how well the record held up when one did.

The Defensibility Rate

Hospitals already track revenue collected, revenue denied, and revenue recovered. Strick proposes a fourth number for the dashboard: defensibility rate, the share of denied records your own team rates as strongly supported. “It answers one question: when the payer came after this claim, did the documentation hold?”

That number also separates documentation issues from payer behavior. Strick shared an example from a client where claims with similar documentation strength produced overturn rates of roughly 70 to 75 percent with one payer and about 10 percent with another. “What does that tell you? You do not have a documentation problem. You have a payer problem.” That is data a hospital can carry into contract negotiations, a return Strick calls “definitely underrated.”

According to Strick, “Pre-bill CDI will not lower your denials volume; it determines whether the billed DRG can be defended when denials arrive.”

Make the Last Controllable Moment Count in Your Pre-Bill Workflow

The workflow itself is, in Strick’s words, unremarkable: concurrent CDI, discharge, final coding, pre-bill clinical review, query if needed, release, payment. “Six of those seven steps already exist in your organization today. I am asking you to add one.”

An additional step changes the starting point for every appeal. An appeals team cannot create clinical evidence; it can only work with what is already in the record. Without a pre-bill review, documentation gaps get discovered during the appeal, the worst possible moment, because by then no one can query.

Or as Strick puts it, “Your appeal team doesn’t have to build the case; they just have to present it. And that is the difference between defending a claim and hoping.”