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.

SCENARIO

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.

CHALLENGE

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.

CHALLENGE

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.

CHALLENGE

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.

CHALLENGE

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.

SOLUTION

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.

SOLUTION

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.

SOLUTION

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

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