Minimize clinical denials to recoup revenue.

Healthcare providers face difficult challenges with managing clinical denials and appeals, which can impact their ability to get paid in full for the services they deliver. These denials of payment are based on medical necessity, clinical validation, length of stay, or level of care and may be concurrent (while the patient is still in-house) or retrospective (after the patient is discharged). AGS Health provides seasoned, experienced clinical resources to support clinical denials and appeals processes to mitigate these challenges. We review denied claims, identify root causes, and craft compelling appeals supported by comprehensive clinical evidence. Leveraging our deep understanding of healthcare regulations and payer requirements, we advocate on your behalf, maximizing your revenue and minimizing financial losses.

Clinical denials and appeals can be handled within clinical authorizations, clinical documentation integrity (CDI), or utilization review (UR). Clinical denials and appeals services provided include:

• Review and analysis of denials focusing on medical necessity, MS DRG/APR DRG downgrades, length of stay, level of care, and subsequent appeals to dispute clinically based denials.
• Corresponding with physicians and hospital departments regarding documentation and supporting clinical indications to defend claims.
• Writing professional letters of appeal.
• Reporting and education on denial trends and critical findings.
• Swift submission of clinical appeals to prevent revenue leakage.
• Simplify revenue cycle management (RCM) workflow and processes.

Benefits

Maximize Revenue Recoup revenue that might otherwise be lost through timely review of denied claims to identify root causes and submitting appeals supported by comprehensive clinical evidence, enhancing financial stability.

Enhanced Efficiency Prevent revenue leakage and simplify workflows through a streamlined approach that increases standardization and reduces manual errors.

Ensure Compliance Ensure compliance with complex healthcare policies with thorough and correct documentation and claims handling that aligns with healthcare regulations and payer requirements.