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Healthcare organizations and physicians have experienced an increase in denials over the past year. These costs impact the revenue for healthcare organizations and physicians. Our experienced denial team identifies and corrects the cause of denials. Our denial team defends and manages your appeal process. Our staff of case managers, registered nurses and certified coders will create a defense for the denial initiated by your payers. They will identify the cause for denial and establish supporting documentation for billed charges. We effectively implement an appeal process with accurate results.
Managing Medical Necessity & Denials

The status of patients at the time of admission or discharge significantly influences the cost and method of the reimbursement that hospitals receive. Therefore, hospitals have a responsibility to ensure that admission and discharge policies are updated and reflect current CMS rules.


In order for admissions to be considered medically necessary under the Medicare program, the patient must have a condition requiring treatment that can be provided only in an inpatient setting. Our staff of experienced Nurse Auditors, Certified Coders and Certified Case Managers work with you to monitor and manage your denials to identify risk areas. Thereby, developing strategies to evaluate these issues. We will review your one-day stays against InterQual criteria and other admission criteria such as Milliman Care Guidelines.

Denial Prevention and Management

Our experience staff can assist in defending and managing your denials and appeal process by:

  • Identifying and correcting the causes of denials and following with Appeals process.

  • Conducting Concurrent Audit Review to verify that charges represent services rendered to the patient are accurate and are ordered by physician and identify and correct any discrepancies.

  • Focusing on clinical documentation improvement by making sure physicians are adequately documenting clinical treatment given to patients in the medical record for proper reimbursement. Such as correct use of CPT codes, modifiers and E&M.

  • Provide necessary support and education to physicians and staff in order to improve clinical documentation.

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