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