Payer Peer-to-Peer
Reconsideration Review
Resolve Medical Necessity Before the Claim is Submitted
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Enhance Revenue Cycle by Reclaiming Revenue Earlier
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Increase Reimbursement
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Improve Revenue Integrity
Overturning Denials Before Claim Submission
Our denial management physician advisors utilize our proprietary database to review payer determinations on previous cases before performing the Payer Peer-to-Peer Reconsideration Review. We advocate on our client’s behalf to resolve medical necessity before the claim is submitted, averaging an exceptional ROI for our partner hospitals. Hold payers accountable and gain actionable insights to improve utilization review.
CASE STUDY:
CLINICAL SUMMARY: Hyperemesis gravidarum 4-day inpatient stay
A 34-year-old patient who was 13 weeks pregnant was admitted to the hospital recently with hyperemesis gravidarum with electrolyte imbalances. The patient had experienced several days of nausea and emesis; she also had a low-grade fever of 100.5 degrees with a white blood cell count of 20k and bicarb of 17. An abdominal MRI showed no appendicitis; urinalysis noted epithelial cells, moderate bacteria, trace protein and ketones. Treating physicians began ceftriaxone for asymptomatic bacteriuria. The patient experienced sudden onset back and pelvis pain with unclear etiology. She was started on morphine. A retroperitoneal ultrasound showed mild right renal fullness. Physicians consulted urology concerned for obstructing nephrolithiasis in the setting of the pregnancy. Urology concluded the patient could have recently passed a stone, but no current stone required management.
The patient’s electrolytes stabilized during the four-day stay and outpatient IV fluids were arranged for given the ongoing hyperemesis gravidarum. There was no urine culture growth, therefore antibiotics were stopped at discharge. The patient had a close obstetrics follow-up post discharge.
