Providers – Denial Management 2018-12-03T14:31:16+00:00
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Denial Management

Clinical denial backlogs happen, but we’re here to help.

These first-level, second-level, and/or final appeals are charged based on a fee-for-outcome or fee-for-service model. Our team is available to assist once you receive a denied claim. Our flexible model allows us to supplement your team when and where you most need it, as you need it. Best of all, we provide root cause feedback designed to improve your processes and clean claims rates – regardless of appeal viability and/or appeal result.

MEDICAL NECESSITY  |  INPATIENT/OUTPATIENT  |  SEVERITY OF ILLNESS

What Our Clients Are Saying

“The quality of the denial letters are stellar, citing the most up-to-date evidence-based literature. The feedback that the Advent team provides serves as a clinician education opportunity so that history does not repeat itself… I find their results effective and their costs reasonable considering their expertise in their field.”

Director of Case Management, Regional Health System

3 THINGS TO KNOW ABOUT
ADVENT’S DENIAL MANAGEMENT SERVICES

90% OVERTURN RATE

Leverage Our Denial Expertise: Our team’s clinical expertise and payer backgrounds deliver correctly appealed denials focused on claims with overturn potential.

FLEXIBLE PARTNERSHIP

Respond to Your Current Needs: Advent flexes to your needs regarding services, admission types (inpatient, outpatient), and volume of cases.

COMPREHENSIVE DEFENSE

We Defend Our Decisions: In the unlikely event of a denial, Advent defends our work throughout the life of the claim – at no additional cost.

Ready to efficiently create effective claims?

CAVO®, our proprietary technology platform, enables revenue cycle management departments of hospitals and health systems to efficiently make decisions regarding claim submissions and appeals. CAVO® allows users to instantly search medical records and quickly find needed information to determine medical necessity for claims.

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Advent client successes with denial appeals

Provider Care: Infant is admitted to the NICU weighing 800 grams and in respiratory distress. Patient received respiratory support and transfusion of packed red blood cells with a two-month length of stay.

Payer Denial: Submitted claim for a Level III NICU stay, but it was paid at a Level II.

Advent Appeal: Documented daily patient monitoring, each IV solution, lab results, and oral feedings until the infant began progressing to change levels.

Result: Successful overturn of appeal.

Provider Care: Patient presented to the ER with an overdose on prescription medication.

Payer Denial: Denied as inpatient and paid as an observation.

Advent Appeal: Based on the specific prescription medication, Poison Control documentation is clear that a 3-day period is required to clear the patient’s body system.

Result: Successful overturn of appeal.

Provider Care: Obtained an authorization. Patient was not exhibiting withdrawal symptoms for this DOS.

Payer Denial: Denied for no authorization.

Advent Appeal: Determined authorization was obtained for Revenue Code 128 but claim submission cited Revenue Codes 124 and 126. Verified that Revenue Code 128 was correct based on patient diagnosis. Requested re-bill and submitted.

Result: Successful overturn of appeal.

Provider Care: Patient was admitted on February 8th.

Payer Denial: Payer denied inpatient claim on February 11th stating patient did not meet LOC criteria.

Advent Appeal: Submitted appeal with documentation that showed the patient’s condition worsened since the initial denial – and now met inpatient criteria.

Result: Initially denied again. Advent submitted a complaint to the state with the complete medical record showing this claim met inpatient LOC criteria per MCG guideline for wound complications.

Request an expert review of your appeal letters

Advent’s RCM experts will review up to two of your appeal letters, provide redline feedback, and complete a 30-minute follow-up consultation. This customized feedback is designed to improve your letter(s) and overturn more denials

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REPORTING ON YOUR BUSINESS

MONTHLY STATUS REPORT

Details your claim inventory status, providing a claim roll-up of the activity taken on the claims, where they currently reside in the process, and final claim resolution.

EXECUTIVE
SUMMARY

Overviews metrics for designated period and may show trends not easily seen within the project. Helps escalate any issues or opportunities for both Advent and client.

ON-TREND
REPORT

Case-by-case review to determine appeal opportunities. Aggregates and outlines the story of your denials plus our recommendations for addressing root causes.

STANDARD
GRAPHS

Illustratively depicts  claims appealed and recovery results. Specific graphs can include appealed amounts by payer and/or denial type plus closures by reasons and/or payers.

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Consulting Services

Our expert, organization-specific consultations related to the lives of cases/claims deliver application of best practices, process improvements, and departmental protocols. Specific offerings include:

  • Evaluating cross-functional processes across departments
  • Streamlining clinical and financial workflows
  • Setting and tracking KPIs
  • Modeling payer contracts

Our goal is creating a collaborative partnership with both parties equally accountable, resulting in highly productive teams and realized revenue.

How one hospital recovered $20+ million in overturned appeals

After determining they needed assistance with first-pass denials, this 600+ bed provider engaged Advent for denial management services. This hospital worked to improve documentation supporting the bill plus pinpoint denial root causes. Results included:

  • Recovery of $20+ million in the first 18 months of partnership.
  • Implementation of process improvements to prevent subsequent denials – including pre-bill reviews – which resulted in overall denial rate decrease of 200+%.
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Watch Now: Medical Claims Review Services

Let’s talk about your needs plus our clinical expertise
and experience with successful appeals.

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855.789.6691