Improving Denial Rates with Appeal Management & Pre-Bill Reviews
When a newly hired operations executive arrived at their 600+ bed acute care hospital in the Northeast, they immediately identified their first challenge: a facility denial rate almost triple the national average. Additionally, their initial assessment determined that this metropolitan hospital lacked the internal resources and skill sets to most effectively challenge medical necessity denials.
The Challenges
As they dug into their role, this operations executive discovered several hurdles that needed to be addressed due to their direct impact on the hospital’s fiscal problems:
Siloed Hospital Departments: Like many providers, the utilization review, case management, and patient financial services departments operated independently—and without efficient inter-department communications.
Appeals and Process Expertise: Staff members possessed the requisite clinical knowledge but not the needed business acumen, subject matter expertise, and payer expertise.
- Length of Stay: When it came to admitting patients, they erred on the side of keeping patients in the hospital to protect clinical liability and accommodate patient preferences.
They 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.
The Solutions
Appeal 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.
Clinical Expertise
After only a few months of reviewing and appealing denials, Advent’s clinical experts were 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—clinical and coding reviews of claims that occur before dropping the bill to the health plan. The hospital contracted with Advent on a per-case basis, and our clinical staff reviewed specific claims prior to being billed to ensure that:
- Documentation supported the service
- Length of stay met inpatient industry criteria
- Billing status aligned with documentation—or made recommendations for billing status changesAd
The Outcome
Appeal Management
Very quickly, the Advent team considerably reduced inpatient denials, and, as a result, the provider’s monthly gross recoveries significantly increased. The hospital recovered more than $20 million across the first 18 months of its partnership with Advent, and also saw its denial rate decreased by two-thirds.
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
With an average of 300 pre-bill claims reviewed monthly across the 12-month project, the hospital’s denial rates were reduced to one-third of what they had been in the year previous to engaging with Advent.
Advent’s success during this pre-bill review project led to an internal pre-bill review department that now performs 100% of these reviews.
The Advent Health Partners Answer
Advent continues to perform appeal management for this hospital. 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.
Our team’s clinical expertise and payer backgrounds deliver correctly appealed denials focused on claims with overturn potential. A 90+% overturn success rate sets Advent’s appeal management services apart from our competitors. As a single vendor solution, Advent provides optional implementation assistance so your team can immediately leverage these strategies and results.
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