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Clinical denials are cases where a hospital’s request for reimbursement for a medical service is denied by the payer. These denials happen due to various factors such as incorrect documentation, medical necessity issues, disagreements in appropriate patient status, and registration issues. As a result of clinical denials, hospitals face financial and operational challenges. Front end denials (denials related to registration/eligibility, authorizations, and medical necessity) account for 41% of all hospital denials, up from 10% just 3 years ago (Change Healthcare, 2022). These denials lead to lost revenue which can negatively impact hospital finances.
While hospitals can appeal denied claims by following the payer’s appeal process, very few denied claims are appealed. Why? This process is often tedious and takes significant time away from providers giving patient care. Additionally, to be successful at these appeals, providers must know each payer’s appeal process, guidelines used, and have a firm understanding of the revenue cycle and billing processes.
This is where Apricity Healthcare Solutions, LLC can help. We will partner with the hospital to not only appeal these denials but also do the necessary follow-up with the payer and track the claim for payment.
Post Payment Audits
Post payment audits are increasingly being utilized by not only governmental agencies but also commercial, Medicare Advantage, and Managed Care Organization payers. As with clinical denials, these audits are tedious and can no longer be ignored by hospitals due to payment recoupments, denial rates increasing audits and extrapolation processes by the payers.
Apricity Healthcare Solutions, LLC can help relieve the burden these audits cause hospitals by completing and managing the appeals needed for the denial as well as prevent the denial by ensuring that all documentation that proves medical necessity is provided when agencies use pull lists or additional documentation requests (ADR).
Denials Prevention and Revenue Capture Consulting
Apricity Healthcare Solutions, LLC provides its contracted hospitals with reports that help identify opportunities for denials prevention and specific payer denial rates. In addition, Apricity Healthcare Solutions, LLC provides consulting services for its contracted hospitals which helps dive deeper into the hospital’s top denial reasons, diagnoses, and payers. With this information, we work with the hospital’s billing, utilization management, case management, and patient access teams to build denial prevention processes into the team’s practices.
Apricity Healthcare Solutions, LLC will also consult with our contracted hospitals to provide utilization management guidance on ensuring patients are placed in the correct status. Gone are the days that you allow the payer to guide your patient status by “offering” observation rate of pay for care that was inpatient appropriate. We will share our knowledge and proven strategies for hospitals to support the inpatient status based on payer policies, regulations, and guidelines.