The current era of declining enrollment and increasing scrutiny is leaving hospitals with fewer admitted patients and more difficult decisions on how to care for them in a way that will produce a positive outcome without unnecessary costs or risk of claims denial. Making timely, accurate decisions regarding admission status and effectively managing the documentation process is proving challenging for many providers.
In the first six months of 2015, 64 percent of RAC denials were overturned on appeal – which suggests providers could have avoided the denial by determining the appropriate admission status and supporting documentation.
Adreima has achieved a 90 percent appeal success rate for clinically related denials
Hospitals are taking advantage of our extensive knowledge of treatment protocols and payer requirements, skill in presenting cases, and commitment to process excellence to make their utilization review more effective.
• End-to-End Services: Adreima serves as an extension of your utilization review team. Our services start with the admission decision support and continues through claims submission. In between, we can update your systems with status recommendations, pursue concurrent authorization, appeal payer level of care decisions, conduct length-of-stay and level-of-care reviews, gather documentation for discharge and more.
• Clinical & Billing Expertise: Adreima has helped clients win many appeals, but our real value is in the many more we have prevented. Our nurses are not only well versed in medical necessity and commercial screening tools, they are extremely skilled in how to present cases to receive payer authorization on the first request.
• Analysis & Recommendations: Adreima goes beyond support on a case-by-case basis. We perform extensive analysis of your length-of-stay reviews, physician referral patterns, payer performance and other measures to provide reports and recommendations to improve processes, institute appropriate checks and balance, and ultimately reduce denials.
Adreima’s Utilization Review services create clarity and competency wherever our clients need support. We can help you solve utilization management challenges and provide a foundation for ongoing improvement.