(Inpatient and Outpatient)
Medical claims may be denied. To deny payment, insurers often challenge the necessity of treatment. When hospitals’ utilization review (U/R) nurses and doctors appeal these denials, they usually argue on the merits of the treatment provided. Yet, many claims are still denied. HLS supplements your U/R department’s efforts by providing attorney muscle to your appeals. HLS identifies the issue, studies the medical record, and applies standard medical guidelines (Milliman or Interqual) to the clinical facts of the case. Once the medical necessity issues are resolved with the payer, HLS continues to follow up and handle billing after payment is received. HLS works diligently with the hospital case management, billing and appeals departments to save time and effort for the client. By having a team collecting on administrative and medical claims, you have a unified approach for all your claims. HLS has been very successful with medical necessity, level of care, medical review denials. To date, HLS has been able to overturn at least 40% of net amount denied.