Denial Prevention
Utilization Management
We overturn denials to increase revenue and shorten revenue cycle with accurate medical necessity determinations to achieve excellence in utilization review.
Second Level Utilization Reviews
Medical necessity or admission status evaluations are sent for clinical judgement to assess level of care or length of stay.
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Payer Peer-to-Peer Reconsideration Reviews
Submission deadlines and lack of resources shouldn’t prevent you from resolving medical necessity before the claim is submitted. Our return on investment is usually 4x, so resolve the claim, get paid and grow your reimbursement.
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Medicare Short Stay Chart Audit Reviews
Short stays (hospital stays of less than two midnights) have a high probability of audit and outside scrutiny. Reduce that probability and increase compliance.
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Discharge Reviews
Our physician advisors use evidence-based, clinical determinations when evaluating discharge appropriateness.
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Utilization Review Education
Benefit from peer-to-peer discussions initiated with the treating physician for case clarification, redirection to a lower level of care, discharge consideration or potential education. Part of our ongoing education efforts, this is also included with our second level assessments.
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Appeal Reviews
Protect your investment by having one of our physician advisors evaluate your denied inpatient stay to assess the probability of success before initiating a formal appeal.
Two physicians review every case.
Our customized, detailed reporting helps our health system partners reinforce revenue integrity by identifying utilization trends that impact quality of care and hospital reimbursement. Ensuring accurate medical necessity determinations upfront is integral in mitigating denials and increasing reimbursement revenue, making the physician advisory component pivotal for revenue cycle optimization.
We customize our hospital client’s quarterly reports to include metrics such as insurance carriers, redirection statistics and insights, length of stay observation cases, internal and payer peer-to-peer insights, appeal review statistics, clinical issues, overall utilization trends, and more.
We meet with our clients throughout the year for utilization management education and discussion to help improve quality of care, compliance and reimbursement. Our quarterly reports include physician-driven documentation aimed at identifying the root causes of denials to ensure our hospital partners are ensuring revenue integrity and optimizing revenue.
Revenue Integrity Physician Advisory
Protect your revenue by reducing denials with medical necessity determinations. Second level assessments are facilitated by licensed, board-certified physicians with both hospital and payer experience who know that accurate admission status is essential for optimizing revenue cycle reimbursement. Our sole focus on utilization management helps our hospital clients improve quality of care, length of stay and revenue.
Denial Management
Overturning denials requires preparation, flexibility and medical judgement that our denial management physician advisors possess from their experiences in the hospital and on the payer side. Payer-specific knowledge is also required for overturning denials to increase reimbursement revenue, which is why we continually update our proprietary payer database to ensure that our clinicians have the most up-to-date information on payer trends and tactics.
