Find and address the root causes of revenue leakage

Many aspects of the mid revenue cycle — coding; charge description master (CDM) maintenance; charge capture; and clinical documentation — can contribute to revenue leakage, leading to:

  • Less net revenue collected
  • More medical necessity payer denials and underpayments
  • Decrease in case mix index (CMI)
  • More manual claim cleanups and edits and an increased cost to collect

These case studies highlight the real-world success some of our customers have achieved.

West Tennessee Healthcare > Mid-Atlantic client >

Mid revenue cycle challenges can take significant time and money to reprocess or appeal. We can help. Our mid revenue cycle solutions include:

  • Coder training and education
  • Coding quality, documentation, and policy assessment
  • Payer coding audits
  • Interim HIM and/or coding management
  • Evaluation and management (E/M) coding audits
  • Charge capture audits
  • Denial and appeal management, leveraging machine learning algorithms
  • Inpatient/outpatient coding guideline development
  • Clinical documentation improvement (CDI)
  • Charge description master (CDM) review and maintenance

The art and science of clinical denials management

Our intelligent denial management solutions — a strategic blend of art and science — can help you reduce costs, cut process times, support patients, and strengthen cash flows.

The science: machine learning algorithms

We apply robotic processing automation (RPA), AI, and machine learning algorithms to denied claims to analyze vast denial data and group cases by attributes such as technical-vs-clinical, remit codes, denial reason codes, and responsible payor. Our system then sorts and assigns accounts to representatives who specialize in the various denial reasons.

The art: human expertise

Timely, accurate clinical appeal submissions are critical to ensuring the best outcomes. This is where we apply our most powerful asset: our people. Our appeal nurses average 25 years of experience in Recovery Audit Contractor (RAC) audits; CMS regulations and appeals; auditing processes for all major health plans; InterQual and MCG (Milliman) guidelines; and clinical documentation … all of which they apply to write custom appeal letters that stand the best chance for positive resolution, for you and your patients.