When the newly hired operations executive arrived at Metropolitan Hospital, the 600+ bed acute care hospital in the Northeast, she immediately identified her first challenge: a facility denial rate almost triple the national average. Plus, her initial assessment determined that this metropolitan hospital lacked the internal resources and skill sets to most effectively challenge medical necessity denials.
- Siloed hospital departments. Like many providers, the utilization review, case management, and patient financial services departments operated independently – and without efficient inter-departmental communications.
- Appeals and process expertise. Staff members possessed the requisite clinical knowledge but not the needed business acumen, subject matter expertise, and payer experience.
- Length of stay. When it came to admitting patients, they erred on the side of keeping patients in the hospital – both to protect clinical liability and accommodate patient preferences.
She knew the hospital needed immediate fiscal improvements, as well as better processes. This hospital needed to prevent denials, improve day-to-day documentation supporting the services, and reduce overall time-to-revenue
This provider’s decision makers knew Advent’s reputation with payers for submitting quality medical necessity appeals and, therefore, requested a proposal for first-pass denial services. If the provider’s initial claim submission resulted in a denial, then Advent would work the denial to reimbursement.
After only a few months of reviewing and appealing denials, Advent was able to pinpoint several of the provider’s root problems:
- Inconsistent documentation leading to incorrect billing and subsequent denials.
- Claims not meeting payer-driven industry criteria.
- Payers not receiving timely information.
Based on these root cause identifications, Advent recommended pre-bill reviews – which are clinical and coding reviews of claims prior to dropping the bill to the health plan. This provider contracted with Advent on a per-case basis, and our clinical staff reviewed specific claims prior to being billed to ensure:
- documentation supported the service,
- length of stay met inpatient industry criteria, and
- billing status aligned with documentation (or made recommendations for billing status changes).
Recovery of more than $20 million across first 18 months of partnership | Denial rates decreased by 67%
Very quickly, the Advent team considerably reduced inpatient denials, and, as a result, the provider’s monthly gross recoveries significantly – and proportionately – increased. Additionally, Advent’s shared education and best practices fostered collaboration between key hospital departments: case management, utilization review, and patient financial services.
Average of 300 pre-bill claims reviewed monthly across 12-month project | Denial rates reduced to 1/3 of the year prior to Advent’s engagement
Advent’s success during this pre-bill review project led to an internal pre-bill review department that now performs 100% of these reviews.