Case Study

Accelerating claims reimbursement with HGS clinical denials advanced recovery

Industries
Healthcare
Solutions
Business Process Optimization
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Business Challenges

Today’s health providers can no longer afford to view clinical denials as the cost of doing business—and that’s because the mounting cost of denials is too high. Research shows that charges denied by payers have doubled to 15%–20% of all claims submitted, at $118 per claim, with the potential for 40%–60% of those denials typically recoverable on appeal.

Summary

Our HGS clinical denials solution delivers advanced claims recovery to beat that industry standard recovery rate. In fact, for one HGS client, our analysis identified potential recoveries at 88%. We drive these breakthrough clinical denials outcomes with a proactive, two-pronged approach to overturn denials and prevent them in the first place. Our clinical denials team delivers this expertise from blended-shore locations for savings of up to 30%.

HGS clinical denials advanced recovery features

Photo of image HGS clinical denials advanced recovery featuresPhoto of image an image of Clinical claims form

The HGS clinical denials advanced recovery approach

Our clinical denial resolution

  • HGS clinician researches root cause for denial by reviewing claim status and payer medical necessity denial response
  • Clinician incorporates end-to-end payer criteria knowledge in targeting denial root cause with mapping of payer medical coverage policy
  • Medical record analysis by our skilled clinicians aim to:
     
    • Recognize gaps
    • Identify crucial missing records needed for favorable appeal response
    • Address missing records with targeted requests
  • HGS clinicians use claim/denial research, payer criteria knowledge, inclusion of targeted medical records, and payer medical necessity denial responses to outline appeal response on clinical denials; our clinical acumen supports denials with documentation
  • HGS administrative support conducts outreach for records requests and denial research calls, with targeted record follow-up on denials missing medical records
  • HGS concludes denials efforts with reporting to identify impact areas like top reasons for denials or propensity-to-pay patterns

Our clinical denial prevention

  • HGS leverages our analytics to identify patterns in denials causes, denial outcomes, and improvement opportunities
  • Our targeted workflow and follow-up process improvement opportunities includes features, such as:
     
    • Prior authorization workflows to request authorizations for all applicable requests to prevent denials for missing information
    • Follow-up on technical denials for opportunities to re-submit with required information
    • Review of accounts for appropriate denials
    • Submission of requests for payer clarifications
    • Workflows to request routine types of medical records missing on denials
  • HGS provides clinician-guided analytics and denial outcome reporting on common denials causes
  • We partner with our provider clients to provide actionable insights into common causes, and we proactively suggest solutions to build sustained improvements

Photo of image Image of figures showing Industry standard: 40%-60% claim denials are recoverable; up to 90% of claim denials are preventable

an image showing HGS advanced recovery differentiators