For Payers

Advanced clinical appeals

Secure savings and ensure accurate claims payment for payers with innovation.

Today’s health plans are challenged with a complex appeals process that can be a significant drain on efficiency, resources, and cash flow.

Inefficient processes and disparate systems contribute to time-consuming resolution and both provider and member dissatisfaction — with potential non-compliance and resulting fines. Factor in steady plan growth, and health plans need to drive toward improved claim payment with workflow, reporting, and analytics expertise.

Our Advanced Clinical Appeals solution provides a flexible, scalable model customizable to the client’s individual appeal health plan requirements, supported by our ability to ramp and flex to the client’s seasonal or volume needs.

For one health plan client, our appeals team delivered operational excellence and innovation to increase revenue by nearly $800,000.

Features of our advanced clinical appeals solution

Clinical, Payer, and Provider Domain Acumen to Drive Savings

Our appeals analysis is guided by an experienced clinical talent pool of nurses located in the US, Philippines, and India, with US-licensed RNs supported by our innovation and technical experts. These blended-shore center of excellence resources deliver expertise at savings of 30%.

Our team has 15+ years of experience with payer clients (Medicare, Medicaid, Medicare Advantage, and commercial), including claims handling, member and provider customer service, eligibility, benefits, pharmacy, coding and clinical review, payment integrity, and payer clinical appeals handling and causes.

Our clinical teams have deep domain expertise in multiple clinical criteria, such as Medicare NCD/LCDs, MCG, InterQual, and clinical payer policies. We also bring 20+ years of provider revenue cycle management (RCM) experience supported by key insights into processing appeals and creating improvements. Our proven track record in effective appeals review determinations, prior authorizations handling, medical necessity review outcomes, and unique clinician development plans across geographies ensures standard decision and clinical knowledge enrichment.

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Innovation to Build Excellence and Meaningful Insights

Our proprietary advanced clinical appeals technology reduces or eliminates the manual effort required for many activities or tasks. Our tech suite handles payer appeals with a closed-loop quality focus, leveraging client customization, analytics for improvements, and total clinical review of appeals processes.

Our platform offers end-to-end (E2E) system integration, appeal analytics, reporting, automated workflows, quality monitoring, PI, and inventory management. Our root-cause analytics drill down by appeal decision types and determine the source of the appeal, by provider, claim types, savings, denial type, and other categories. We leverage analytics to look at historical data for appeal trends and provide meaningful insights for clients on potential improvements.

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Process Excellence to Enhance Quality, Turnaround Time

Our clinical appeals solution leverages our signature quality approach — comprising end-to-end insights, payer criteria knowledge, and provider RCM expertise knowledge — to laser-focus on upholding appeals accurately and quickly identifying medical record gaps to finalize appeal outcome.

Our standard ISO-certified quality process and clinician education program ensure highest quality in clinical decision accuracy and verification of appeal outcome results. Our turnaround time outperforms service levels to proactively address shortfalls.

Advanced clinical appeals:
The client incorporation solution

Our team comprises clinicians who provide:

  • The right knowledge and skill set needed for appeal type
  • Flexible, scalable model to match our clients’ geographical and account requirements
  • Training from tested model for providing the clinician with a solid foundation to process appeals consistently and at high quality level

Our clinicians will:

  • Train on client-facing platforms and process payer appeals within client environment
  • Bring deep domain expertise in end-to-end payer criteria in assessing appeal case as a whole, incorporating additional information submitted, and assigning outcome supported by client policies and clinical guidelines

We partner with clients within their own environments, including:

  • Dashboard reporting on appeals trends and outcomes
  • Appeals analytics to analyze current appeal statistics, outcomes, and historical trends providing meaningful insights on patterns by provider, appeal type, or other categories
  • Appeals improvement through workflow efficiencies or other process improvements (e.g., one client experienced a 32% increase in TAT through assignment queue improvements)
  • ISO certification with standard process for appeals quality and proven high accuracy in clinical acumen on payer reviews
  • Design thinking and cocreation with clients to design workflows, reporting, and other solutions that work hand-in-hand with clients in their own environments
  • Actionable insights into common appeals trends and proactive suggestions to build sustained improvements

Advanced clinical appeals:
The external solution

Clients also have option to include all above Sagility clinician and BPO support outlined in the client incorporation solution and elect to utilize our proprietary clinical review platform instead of their own environment

Our exclusive clinical review platform provides:

  • A total solution for health plan appeals to be received, medical record storage, appeals reviewed, and appeals outcome notification
  • End-to-end system integration for client resources, Sagility clinicians, and quality resources for appeals review processes
  • Incorporations of appeals analytics, reporting, automated workflow, quality monitoring, process improvement, and inventory management
  • Client customization and workflows tailored to client requirements
  • Client view to monitor appeals outcomes, TAT, and quality scores

Sagility points of differentiation

  • End-to-end experience to lend deep domain expertise in health plan appeals processing and improvements
  • Extensive payer criteria knowledge from end-to-end medical necessity UM/CM/PI experience
  • 20+ years provider RCM experience
  • 6+ years supporting payer UM and prior authorizations
  • Proprietary appeals/denials technology solution supported by design thinking to optimize results
  • Analytics expertise for appeal data and target appeal improvement
  • Proven high accuracy in clinical appeal decisions with extensive focus on quality
  • Unique clinician development plan across delivery centers
  • Extensive Medicare, Medicare Advantage, and commercial health plan experience
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