Whether you are looking for full outsourcing or as-needed assistance, we’re available to partner with you to fight the toughest medical necessity and clinical validation (DRG) denials.

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Denials

We overturn 89% of commercial insurance denials at the peer-to-peer stage!

Commercial payors are denying at an increasing and alarming rate. Building a strong defense to this trend is necessary. Payors initially deny about 9 percent of hospital claims. With a 43% increase in commercial payor denials this year, it is vital for your hospital to have a plan!

When a denied claim is received, timing is critical to determine whether your organization agrees with the auditor’s findings. We offer deep subject matter expertise in denials resolution and can help your organization recoup reimbursement earned for providing patient care.

Whether you are looking for full outsourcing or as-needed assistance, we’re available to partner with you to fight the toughest medical necessity and clinical validation (DRG) denials.

Peer-to-Peer Support

Our experienced physician advisors have established valued, credible relationships with many of the health plan medical directors through providing peer-to-peer support for our clients. Once a peer-to-peer is requested, we contact the payor within 24 hours to coordinate and resolve a peer-to-peer review. The outcome of the review is immediately communicated back to the client.

Peer-to-Peer Coaching

When insurance companies decline to work with third-party vendors, we coach your clinicians to appropriately manage and overturn denials at the peer-to-peer stage.

Appeals Support

Our physician advisors review medical necessity and clinical validation denials to determine whether medical necessity was present and/or proper DRG assignment. We organize, coordinate and formulate a letter of appeal using evidence-based medical literature, and assist in following the denial through to the second and third levels of appeal, including discussions and negotiations with the administrative law judge (ALJ).

Our appeals support process

  1. Send the denial information and supporting documentation to our secure inbox.
  2. We advise you of whether an appeal is warranted and, if so, an appeal letter will be authored and returned.
  3. We author effective appeal letters with references to guidelines and evidence-based medicine.

Contract Review

We’ve appealed thousands of cases and are knowledgeable in contract language. We help organizations understand each payor’s contract and appeals process to prepare the denials team to more efficiently manage denials. It is vital for organizations to review each commercial payor contract, managed care and fee-for-service plan, as the appeals process will vary according to payor.

Contact us to learn more about our denials management services.

Our Services

We break down departmental silos in hospital organizations through the unification of clinical documentation across quality, utilization, denials and CDI.

Physician Advisor Programs

Quality

  • Patient Safety Indicators
  • Hospital Acquired Conditions
  • Mortality Risk Adjustment Optimization

Utilization

  • Status Assignment
  • Medical Necessity
  • Extended Stay Reviews

Denials

  • Peer to Peer Support
  • Appeals Support
  • Contract Review

CDI

  • Documentation Education
  • Case Reviews
  • Query Support

LTAC Documentation

IRF Education

Speaking Engagements

Get Credit For The High-Quality Care You Provide!