Case Study: Improving Denial Rates with Appeal Management 2019-02-20T13:10:32-06:00

PROVIDER SERVICES

Case Study

Improving Denial Rates with Appeal Management
& Pre-Bill Reviews

METROPOLITAN HOSPITAL  |  600+ BEDS

When the newly hired operations executive arrived at 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.

CHALLENGES

As she dug into her role, this operations executive discovered several hurdles that needed to be addresses because of their direct impact on the hospital’s fiscal problems.

  1. Siloed hospital departments. Like many providers, the utilization review, case management, and patient financial services departments operated independently – and without efficient inter-departmental communications.
  2. Appeals and process expertise. Staff members possessed the requisite clinical knowledge but not the needed business acumen, subject matter expertise, and payer experience.
  3. 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

What Our Clients Are Saying

“Advent’s platform delivers reimbursements to clients for wrongfully denied claims, but what I found most appealing was the combination of valuable feedback, process improvements, and customized reporting that added transparency to our business processes.”

Operations Executive, Metropolitan Hospital

SOLUTIONS

Denial Management

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.

Pre-Bill Reviews

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).

What Our Clients Are Saying

“Being able to prevent some of these problems before we ever dropped the bill was really powerful. We were even closer to getting our DNFB to three days or fewer, reducing our rate of denials, and winning by getting the claim paid correctly the first time.”

Operations Executive, Metropolitan Hospital

RESULTS

Denial Management

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.

Pre-Bill Reviews

Average of 300 pre-bill claims reviewed monthly across 12-month project | Denial rates reduced to 1/3 of 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.

“We delivered proof that pre-bill reviews prevent denials and narrow time-to-revenue. We are happy to have worked ourselves out of this job, as it demonstrates true success for both this provider and its patients.”

VP of Clinical Operations, Advent

TODAY

Advent continues to perform denial management and consulting services for this provider. Not only does Advent continue to recover significant monthly dollars on this provider’s behalf, but our team’s feedback is also utilized to the provider’s advantage during managed care contract negotiations with payers.

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