Customer’s Problem:

Hospital claims were denied for various patient access related issues. Client requested for a special project to perform root cause analysis, review claims, overturn denials and forecast cash opportunities.

Solution:

• dentify patient access related denials by parsing 835 responses from the payor
• Separate denial codes relevant to patient access and list the descriptions
• Segregate denials into Fatal and Non-fatal based on the financial impact

• Prioritize claim based on its age and dollar value
• Perform pre-call analysis and research payor portals to know the claim status
• Follow-up with insurance companies for payment
• Send reconsiderations followed by appeals to overturn denials
• Document progress and collection efforts

Outcome:

• Pena4 managed a denial overturn rate of 48%, which is in line with the industry standards
• Defined mitigation plans to identify potential claim denials and address them proactively
• Best practices were documented and shared with the client for further adherence