Outpatient Appeal Management at Northeast Health System

Nov 16, 2020

The Challenges

An extensive Northeast health system, consisting of 30+ hospitals and more than 7,000 beds, found it challenging to manage their outpatient appeal managements.

While the business operations were largely centralized, the limited clinical resources tasked with defending denied claims were navigating multiple EMRs and systems, as well as having to write persuasive appeals for both inpatient and outpatient denials. Inpatient denials (representing higher dollars) were prioritized, causing outpatient claims (tied to smaller dollars) to be mostly unworked and written off. The health system recognized it needed to update its processes to be able to improve outpatient denial management.

Effectively, the health system had two options:

  1. Hire additional staff and split inpatient/outpatient claim reviews.
  2. Source for a partner to remedy their staffing challenges and shortages.

The health system knew clinical resources that specialize in writing authoritative claims appeals—specifically those for medical necessity claims—are difficult to obtain and retain. Most of the health system’s challenges associated with creating a new business unit specializing in outpatient recovery focused on generating an appropriate ROI, as outlined below:

  • Hiring and/or reallocating clinically-skilled employees, like RNs, to overturn smaller dollar denials, especially during a nursing shortage.
  • Onboarding new reviewers, plus diminishing productivity of existing staff who are delivering training.
  • Allocating resources to build an effective, systematic claims review process specific to outpatient.

The Solution

After weighing its options to address both inpatient and outpatient clinical claims strategically, the health system selected TREND as its exclusive outpatient appeal management partner.

By partnering with TREND, the health system was able to dedicate internal RNs to inpatient denials, while leveraging our clinical expertise for all outpatient denials.

TREND’s historical overturn success and unique perspective on outpatient denials gave the health system confidence that TREND was the right partner for this initiative.

The Outcome

By the eighteen-month mark into the partnership with the health system, we had been able to recover $31MM and achieved a 94+% overturn success rate.

One part of our client success strategy included lowering the claim dollar amount threshold by $1,000 to review a higher volume of claims which previously would have been written off by the health system.

In addition to these recovery efforts, TREND’s outpatient denial management platform also delivers claim-level denial trend reporting and related best practice recommendations to the health system’s leadership team. This collaborative and comprehensive discussion delivers process improvements to help prevent denials going forward.

Every month, the TREND Operations team meets with the health system’s leadership to discuss strategy and tactics behind the denials TREND can potentially overturn, as well as root cause and process improvements for those TREND cannot. This root cause feedback—combined with quick appeal turnaround times, aggressive payer follow-up, and overall recovered dollars—helps ensure TREND will play an essential role in this health system’s business for many years to come.

The TREND Health Partners Answer

Our team’s clinical expertise and payer backgrounds deliver correctly appealed denials focused on claims with overturn potential. A 90+% overturn success rate sets TREND’s appeal management services apart from our competitors. Additionally, our revenue integrity solutions team identifies root cause trends for your organization’s denials and delivers actionable recommendations. As a single vendor solution, TREND provides optional implementation assistance so your team can immediately leverage these strategies and results.