With an ever-changing regulatory landscape and increasing demands on healthcare providers, case management departments are left scrambling to comply with a myriad of regulations and clinical demands. Moreover, dealing with peer-to-peer clinical denials and administrative appeals is often an overwhelming and uphill battle, which takes away precious time from concentrating on patient care.
Current solutions in the industry, such as avoiding denials through physician advisory companies, are not entirely adequate. While physician advisers can assist in avoiding denials, denials due to lack of medical necessity are unavoidable. In those cases, revenue is lost either through self-denial or by lack of collections. Submission of clinical appeals without a legal argument will most likely result in further denials. In order to recover lost revenue, healthcare providers should partner with a law firm that can successfully represent them and identify collectible denials.
HLS appeals medical necessity denials and adds a legal twist to an otherwise clinical appeal, with proven success. We overturn over 50% of gross denials due to admission, delay in care, level of care, and discharge issues. We provide feedback regarding denial root causes, denials for lack of documentation, and denials by DRG/diagnoses.
Sample Issues appealed:
- Delays in discharge/placement/procedure
- Lack of concurrent review
- Level of care
- Medical necessity
- Observation vs. inpatient