Clinical Appeals Management

We manage every step of the appeals process to recover revenue lost to inappropriate denials.

Clinical Appeals Management is a critical component of hospital revenue integrity strategy. We assist you by ensuring you receive accurate reimbursement for the services you provide through the identification, management and education required to improve claims recovery efforts.

As part of our provider solution, our clinical specialists review claims along with medical records for medical necessity. We identify the services rendered and validate that the appropriate levels of care are billed correctly, addressing issues regarding documentation, lack of medical necessity and plan of care. We manage every step of the clinical appeals process through:

  • Review and analysis of denials
  • Writing professional appeal letters
  • Quality assurance review
  • Submission
  • Follow-ups
  • Reporting & education

 

Experienced Appeals Specialists

When it comes to the appeals management of clinical denials, knowledge is key to resolving and overturning claim denials. Our clinical appeals team of Registered Nurses (RNs) and Compliance specialists are employed on-shore, and have an average of over 20 years of experience. They hold multiple of the following credentials: RN, CCS, CDI, LNCC, C-DAM, CCS-P, CDIP, CCDS, RHIA, RHIT and various audit and compliance credentials.

Having an in-depth understanding of payer specific medical policies, healthcare statutes and national guidelines, our specialists thoroughly review denied claims, write an expertly written appeals letter, and provide insight and strategies to prevent future avoidable denials.

Focus Areas

  • Behavioral Health
  • Chemotherapy infusion services per NCD/LCD criteria
  • CMS Inpatient only services/procedures
  • DOU
  • DRG/APR disputes
  • ICU
  • Inpatient level of care downgraded to Observation status
  • Labor & Delivery
  • Level of Care & Severity of Illness
  • Medical Necessity
  • Medical/Surgical
  • Newborn Nursery
  • NICU levels I-IV
  • Oncology
  • Outpatient surgeries/procedures
  • Pediatrics
  • PICU
  • RAC
  • Rehabilitation
  • Telemetry
  • Trauma

Through a comprehensive root cause analysis of the denials, education and recommendations, we will share strategies to support your long term goals in denial reduction.