Outpatient Denial Management at Northeast Health System

/ OUTPATIENT / DENIAL MANAGEMENT / 

This extensive Northeast health system, consisting of 30+ hospitals with more than 7,000 beds, found it challenging to work all of their outpatient claims appeals.

THEN

While the business operations were largely centralized, the limited clinical resources tasked with defending denied claims were navigating multiple EMRs and systems, as well as having to write persuasive appeals for both inpatient and outpatient denials. Inpatient denials (representing higher dollars) were prioritized, causing outpatient claims (tied to smaller dollars) to be mostly unworked and written off. The health system recognized it needed to update its processes to be able to capture outpatient revenue. Effectively, the health system had two options.

  1. Hire additional staff and split inpatient/outpatient claim reviews.
  2. Source for a partner to remedy their staffing challenges/shortages.

The health system knew clinical resources that specialize in writing authoritative claims appeals – specifically for medical necessity claims – are difficult to obtain and retain. Most of the health system’s challenges associated with creating a new business unit specializing in outpatient recovery focused on generating an appropriate ROI, as outlined below.

  • Hiring and/or reallocating clinically-skilled employees, like RNs, to overturn smaller dollar denials, especially during a nursing shortage.
  • Onboarding new reviewers, plus diminishing productivity of existing staff who are delivering training.
  • Allocating resources to build an effective, systematic claims review process specific to outpatient.

 

By 2022, the U.S. Bureau of Labor Statistics projects the need for 1.1 million new RNs to keep up with growing healthcare needs and to replace retiring nurses.

Let Advent free up these limited clinical resources for you!

NOW

After weighing its options to address both inpatient and outpatient clinical claims strategically, the health system selected Advent as its exclusive outpatient denial management partner. We are capable of taking on clinical outpatient claims, unlike many other vendors, and work as an extension of the business office. By partnering with Advent, the health system can dedicate internal RNs to inpatient denials, while leveraging our clinical expertise for all outpatient denials. Advent’s historical overturn success and unique perspective into outpatient denials gave the health system confidence that Advent was the right partner for this initiative.

RESULTS

Eighteen months into Advent’s partnership with the health system, we have been able to recover $31M and achieved a 94+% overturn success rate. One part of our client success strategy included lowering the claim dollar amount threshold by $1,000 to review many more claims, which previously would have been written off by the health system.

In addition to these explicit recovery efforts, Advent’s outpatient denial management platform also delivers claim-level denial trends and related best practice recommendations to the health system’s leadership team. This collaborative and comprehensive reporting and discussion deliver process improvements to help prevent denials going forward.

Every month, the Advent Operations team meets with the health system’s leadership to discuss strategy and tactics of the denials Advent can potentially overturn, as well as root cause and process improvements for those Advent cannot. This root cause feedback – combined with quick appeal turnaround times, aggressive payer follow-up, and overall recovered dollars – helps ensure Advent will play an essential role in this health system’s business for many years to come.