Case Study: Healthcare

US hospital system achieves 80+% overturn of denials

Overview

During the pandemic, a US healthcare provider needed help in addressing their low rate of overturned claims denials. Sagility conducted a deep-dive analysis to identify and address gaps across three key areas:

Claims denied for additional documentation.
Medical necessity denials.
Claims denied for missing or incorrect prior authorization.

Our investigation into root causes, combined with our deep domain knowledge and analytics/workflow tools, yielded remarkable results for this client at a time when they needed the financial boost the most.

70%of clinical denials eligible for appeal

62%improvement in outpatient claim clinical denials

84%denial overturn rate

Client background

A longtime Sagility client, this healthcare delivery system has dozens of hospitals and continuing care locations across the US.

Business challenge

With more than 40% of their denied claims pending clinical review, this client was missing a key process within their clinical review to determine inaccuracies and documentation-request errors in payment denials.

The solution

Led by a team of clinical experts, Sagility executed the clinical denials management support based on a three-pronged approach.

A detailed investigation of root causes for the low clinical denial overturn percentage

This included:

Analyzing the client’s current denial management process for any gaps.
Conducting an historical analysis of prior denial data for trends on denials types, high and low dollar trends, what areas were appealed, overall % of appeals, and claim-level data for true clinical denial root cause.
Reviewing existing medical records submission process examined for any opportunities.

Engagement of registered nurses with experience working in medical necessity reviews

These nurses had experience with many of our payer clients, including knowledge of not just clinical decision guidelines, but also payer requirements in clinical denials and their origins, such as payment integrity audits and other clinical audits.

Application of robust analytics and workflow tools

These included:

BI analytics and reporting dashboards.
Customized client and denial trend/root-cause reporting.
Predictive analytic models for future denial trends and payer related insights.
Automated and structured denial and priority workflows.
Customized appeal templates.
NLP/ML/AI insights on medical record documentation trends by service denied and payer policy.

Results

Sagility successfully addressed gaps in claims denied for additional documentation, medical necessity denials, and claims denied for missing or incorrect prior authorization. The clinical denials work was successful from service and offshore support perspectives.

73% of claims in these areas were fast-tracked for early improvements.

70%of clinical denials could be appealed. Previously, the client would have written these off.

60-62%immediate impact across 5 facilities with stringent focus on outpatient inpatient, high-dollar, and all specialties of clinical denials.

84%denial overturn rate.

$1.5 million in recouped annual revenues for the first 5 client facilities, and Sagility has set the bar high for even greater ROI for the client.

Global locations

USA • India • Philippines • Jamaica • Colombia

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