Claim denials have always been the way of life for members of the revenue cycle team. While technical denials have nothing to do with the care provided to the patient, the financial effects can add up. In many cases the fixes to technical denials are relatively simple and in fact many could likely have been prevented with more robust and integrated processes on the front end, utilizing innovative technologies such as robot process automation, artificial intelligence, and machine learning, resulting in payments that are faster and more accurate.
R1 Physician Advisory Solutions, with a staff of over 130 physicians, help healthcare providers navigate the regulatory environment by focusing on concurrent recommendations to increase billing compliance as well as success on retrospective appeals.
A multi-disciplinary team comprised of professional in clinical medicine, government and insurance regulation, and coding and clinical documentation manages the appeal process and provides root cause analysis for denials to help prevent future occurrences.
Utilizing nurse review criteria, remote utilization review specialists (RNs) provide the initial, concurrent or retrospective review of the medical record to determine if an ordered level of care is appropriate.
Physicians perform retrospective batch audits focusing on clinical documentation and regulatory guidelines to find opportunities and make recommendations in the areas of admission status, medical necessity and length of stay.
Licensed physicians conduct admission status review supported by medical literature and in accordance with Medicare rules and regulations.
Experienced physician advisors discuss and work to overturn concurrent commercial denials with payer medical directors.
Physicians design and lead customized training programs for case management, physician advisors or attending physicians.
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