Denial Management

Improving Denial Rates with Appeal Management & Pre-Bill Reviews

Improving Denial Rates with Appeal Management & Pre-Bill Reviews

When a newly hired operations executive arrived at their 600+ bed acute care hospital in the Northeast, they immediately identified their first challenge: a facility denial rate almost triple the national average. Additionally, their initial assessment determined that this metropolitan hospital lacked the internal resources and skill sets to most effectively challenge medical necessity denials.

The Challenges

As they dug into their role, this operations executive discovered several hurdles that needed to be addressed due to their direct impact on the hospital’s fiscal problems:

  • Siloed Hospital Departments: Like many providers, the utilization review, case management, and patient financial services departments operated independently—and without efficient inter-department communications.
  • Appeals and Process Expertise: Staff members possessed the requisite clinical knowledge but not the needed business acumen, subject matter expertise, and payer expertise.
  • Length of Stay: When it came to admitting patients, they erred on the side of keeping patients in the hospital to protect clinical liability and accommodate patient preferences.

They knew the hospital needed immediate fiscal improvements, as well as better processes. This hospital needed to prevent denials, improve day-to-day documentation supporting the services, and reduce overall time-to revenue.

“TREND’s platform delivers reimbursements to clients for wrongfully denied claims, but what I found most appealing was the combination of valuable feedback, process improvements, and customized reporting that added transparency to our business processes.”

– Operations Executive, Northeast Regional Metropolitan Hospital

The Solutions

Appeal Management

This provider’s decision makers knew TREND’s reputation with payers for submitting quality medical necessity appeals and, therefore, requested a proposal for first-pass denial services. If the provider’s initial claim submission resulted in a denial, then TREND would work the denial to reimbursement.

Clinical Expertise

After only a few months of reviewing and appealing denials, TREND’s clinical experts were able to pinpoint several of the provider’s root problems:

  • Inconsistent documentation leading to incorrect billing and subsequent denials
  • Claims not meeting payer-driven industry criteria
  • Payers not receiving timely information

Pre-Bill Reviews

Based on these root cause identifications, TREND recommended pre-bill reviews—clinical and coding reviews of claims that occur before dropping the bill to the health plan. The hospital contracted with TREND on a per-case basis, and our clinical staff reviewed specific claims prior to being billed to ensure that:

  • Documentation supported the service
  • Length of stay met inpatient industry criteria
  • Billing status aligned with documentation—or made recommendations for billing status changes

“We delivered proof that pre-bill reviews prevent denials and narrow time-to-revenue. We are happy to have worked ourselves out of this job, as it demonstrates true success for both this provider and its patients.”

– Deborah HorneVP, Clinical Operations at TREND Health Partners

The Outcome

Appeal Management

Very quickly, the TREND team considerably reduced inpatient denials, and, as a result, the provider’s monthly gross recoveries significantly increased. The hospital recovered more than $20 million across the first 18 months of its partnership with TREND, and also saw its denial rate decreased by two-thirds.

Additionally, TREND’s shared education and best practices fostered collaboration between key hospital departments: case management, utilization review, and patient financial services.

Pre-Bill Reviews

With an average of 300 pre-bill claims reviewed monthly across the 12-month project, the hospital’s denial rates were reduced to one-third of what they had been in the year previous to engaging with TREND.

TREND’s success during this pre-bill review project led to an internal pre-bill review department that now performs 100% of these reviews.

The TREND Health Partners Answer

TREND continues to perform appeal management for this hospital. Not only does TREND continue to recover significant monthly dollars on this provider’s behalf, but our team’s feedback is also utilized to the provider’s advantage during managed care contract negotiations with payers.

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. As a single vendor solution, TREND provides optional implementation assistance so your team can immediately leverage these strategies and results.