U.S. Hospital System Achieves 80+% Overturn of Denials
Amid the pandemic, a prominent US healthcare provider faced challenges with low overturn rates of claim denials. Partnering with Sagility, they implemented a comprehensive solution that delivered exceptional results, improving denial overturn rates and efficiency.
About the Client
Our client, a major US healthcare provider, was grappling with the impacts of the pandemic. With already demanding pressures on their resources, they were battling a low overturn rate of claim denials.
Inefficient Denial Management
The process was scattered and didn’t support the effective identification of trends or in-depth analysis of denial types. This inefficiency was a barrier to progress, stifling opportunities to rectify the recurring issues and prevent future denials.
Limited Root-Cause Analysis
There was a lack of comprehensive analysis of denial data at a granular level. The ability to scrutinize individual cases, identify root causes and implement targeted solutions was lacking, leaving many denials unchallenged and unresolved.
Poor Medical Records Submission Process
The client’s existing process for submitting medical records lacked optimization, resulting in lost opportunities to rectify denied claims or preempt potential issues.
Inadequate Understanding of Payer Requirements
Navigating the complex maze of payer-specific requirements was a challenge. Misunderstandings or lack of knowledge about these requirements led to a higher rate of denials.
Thorough Investigation of Root Causes
Sagility performing a line-by-line analysis of the current denial management process, identifying gaps and opportunities for improvement. We ordered a historical analysis of prior denial data, identifying denial types, high and low-dollar trends, appeal areas, and appeal percentages. We delved into claim-level data to better understand the key cause of clinical denials.
Expert Engagement
Our team enlisted the help of registered nurses with experience in medical necessity reviews. These nurses had extensive experience with our payer clients. They possessed knowledge of clinical decision guidelines and their origins, such as payment integrity audits. This allowed us to ensure the medical necessity reviews were conducted correctly.
Robust Analytics and Workflow Tools
Sagility applied powerful technology in the form of BI analytics, reporting dashboards, custom client and denial trend/root-cause reporting, predictive analytic models for future denial trends and payer-related insights, and automated and structured denial and priority workflows. Customized appeal templates were created, and NLP/ML/AI was employed to generate insights on medical record documentation trends by service denied and payer policy.
RESULTS
The Sagility solution successfully addressed the significant gaps, leading to marked improvements.
70%
of Clinical Denials
Became Eligible for Appeal
84%
Rate
of Denial Overturns
62%
Improvement
in Outpatient Claim Clinical Denials
