Case Study: Healthcare
15-20%of submitted charges are denied by payers
40-60%of denials are recoverable on appealThe solution
Our HGS clinical denials solution delivers advanced claims recovery to beat that industry standard recovery rate. In fact, for one HGS client, our analysis identified potential recoveries at 88%. We drive these breakthrough clinical denials outcomes with a proactive, two-pronged approach to overturn denials and prevent them in the first place. Our clinical denials team delivers this expertise from blended-shore locations for savings of up to 30%.
The HGS clinical denials advanced recovery approach:
Our clinical denial resolution
- HGS clinician researches root cause for denial by reviewing claim status and payer medical necessity denial response
- Clinician incorporates end-to-end payer criteria knowledge in targeting denial root cause with mapping of payer medical coverage policy
- Medical record analysis by our skilled clinicians aim to:
- Recognize gaps
- Identify crucial missing records needed for favorable appeal response
- Address missing records with targeted requests
- HGS clinicians use claim/denial research, payer criteria knowledge, inclusion of targeted medical records, and payer medical necessity denial responses to outline appeal response on clinical denials; our clinical acumen supports denials with documentation
- HGS administrative support conducts outreach for records requests and denial research calls, with targeted record follow-up on denials missing medical records
- HGS concludes denials efforts with reporting to identify impact areas like top reasons for denials or propensity-to-pay patterns
Our clinical denial prevention
- HGS leverages our analytics to identify patterns in denials causes, denial outcomes, and improvement opportunities
- Our targeted workflow and follow-up process improvement opportunities includes features, such as:
- Prior authorization workflows to request authorizations for all applicable requests to prevent denials for missing information
- Follow-up on technical denials for opportunities to re-submit with required information
- Review of accounts for appropriate denials
- Submission of requests for payer clarifications
- Workflows to request routine types of medical records missing on denials
- HGS provides clinician-guided analytics and denial outcome reporting on common denials causes
- We partner with our provider clients to provide actionable insights into common causes, and we proactively suggest solutions to build sustained improvements
HGS clinical denials advanced recovery features
Clinical and payer domain acumen to drive savings
Our claims analysis is guided by an experienced clinical talent pool located in the U.S., Philippines, and India with U.S.-licensed RNs and licensed coders supported by our innovation and technical experts. These blendedshore Center of Excellence resources deliver expertise at a savings of 30%. With 20 years of experience with payer clients, we have a proven track record in effective cause determination, eligibility, prior authorization and medical necessity, and identification of crucial missing medical record documentation needed for favorable appeal response.
Process excellence to enhance quality, turnaround time
HGS’s clinical denials solution provides targeted follow-up on technical denials for prior authorization workflows to prevent denials for missing authorization. Our closed-loop quality approach—comprising end-to-end insights and payer criteria knowledge—laser-focuses on payer denial and quickly identifies medical record gaps to resolve denial response. Our turnaround time addresses denials within payer appeal time and outperforms service levels to proactively address shortfalls.
Innovation to build meaningful insights, prevent future denial
Our robotic process automation (RPA) reduces or eliminates the manual effort required for many activities or tasks. HGS’s root-cause analytics drill down by denial causes and determine the source of the health system’s denied claims by denial reason, by payer, by owner—and by admitting office, business office, health information management (HIM) system, clinician, or hospital service. We leverage propensity-to-recover analytics to focus our advanced recoup on highest dollar or highest collection frequency claims.
Results
Industry standard: 40% – 60% of claim denials are appealable and potentially recoverable
Research shows that up to 90%of denied claims are preventable.
