Appealing clinical denials yields millions
A large U.S. healthcare organization sought help to recover millions of dollars in backlogged cases and establish better practices to prevent denials.
When insurers and other payers decline to cover patient costs for medical treatments the denials can severely impact financial performance.
Many healthcare organizations resign themselves to writing off losses—potentially millions of dollars annually—due to inexperienced resources, unfamiliarity with payer-specific criteria and lack of standard processes. Additional reasons for not appealing include ineffective clinical documentation, inappropriate management of the level of patient care and reactive/delayed practices for communicating with payers.
A large US healthcare organization sought help from Accenture to pursue three goals:
Accenture and the client worked together to exceed the initial recovery goal of $2.1 million by a large margin. In roughly six months, the project team recouped more than three times the initial goal: $6.7 million.
"Our mindset is ‘everything is appealable’, rather than looking for only the low-hanging fruit, we harvest the whole tree."
– DAVID BALDERSON, Senior Manager, Accenture Health
This Provider sought help from Accenture to establish a baseline of recouping funds from outstanding clinical denials.
This Health Provider operates several hospitals, nearly 20 urgent-care centers and almost 100 physician practices in the southern United States.
Rather than writing off millions of dollars in denials due to a lack of resources and expertise, the Provider wanted a new, more aggressive approach.
Accenture outlined a two-pronged approach: Recovering millions of dollars in cases since October 2015 and establishing better practices for appeals.
The gains topped the $7 million mark as of May 1, 2017 and the scope of the initiative continued to expand due to the recent acquisition of another facility with a backlog of denials.
In addition to the clinical denials program, Accenture is working with the client on multiple fronts to transform care management. Accenture is assisting with assessments made in emergency departments, suggesting ways to reduce excess days in care, streamlining discharge procedures, and centralizing functions and processes across facilities in the expanding healthcare network.
The project team greatly exceeded the initial target of $2.1 million in roughly six months.
Amount recovered in 1 month
The client was able to recover more than 3X the initial goal
Amount recovered in 6 months