Clinical denials advanced recovery

Beating the 40-60% industry standard claims reimbursement rate with root-cause analysis, audits, analytics, right-shored resources, and more

Today’s health providers can no longer afford to view clinical denials as the cost of doing business. The mounting cost of denials is too high.

Research shows that charges denied by payers have doubled to 15–20% of all claims submitted, at an average rework cost of $118 for hospital claims and $25 for professional claims, with the potential for 40–60% of those denials typically recoverable on appeal.

Our HGS clinical denials recovery solution delivers advanced claims reimbursement 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%.

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HGS clinical denials advanced recovery features

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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 blended-shore 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.

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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.

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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.

Industry standard:
4060%of claim denials are appealable
and potentially recoverable

Research shows:
up to 90%of denied claims are preventable

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

Clinical and coding audits

  • 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
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Case Study

US hospital system achieves >60% overturn of denials and a projected $.3 million in annual savings

A US healthcare provider needed help in addressing claims denials. HGS addressed gaps across three key areas — claims denied for additional documentation, medical necessity denials, and claims denied for missing or incorrect prior authorization — and delivered a financial boost when the client needed it most.

HGS advanced recovery differentiators

HGS advanced recovery differentiators
Axispoint accreditation case management

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