Apricity Services

Clinical denials are cases where an organization’s request for reimbursement for a medical service is denied by the payer. These denials happen due to various factors such as incorrect documentation, medical necessity issues, disagreements in appropriate patient status, and registration issues. As a result of clinical denials, healthcare organizations face financial and operational challenges. Front end denials (denials related to registration/eligibility, authorizations, and medical necessity) account for 41% of all hospital denials, up from 10% just 3 years ago (Change Healthcare, 2022). These denials lead to lost revenue which can negatively impact operational finances. 

While healthcare organizations can appeal denied claims by following the payer’s appeal process, very few denied claims are appealed. Why? This process is often tedious and takes significant time away from providers giving patient care.  Additionally, to be successful at these appeals, providers must know each payer’s appeal process, guidelines used, and have a firm understanding of the revenue cycle and billing processes. 

This is where Apricity Healthcare Solutions, LLC can help. We will partner with you to not only appeal these denials but also do the necessary follow-up with the payer and track the claim for payment.

Post payment audits are increasingly being utilized by not only governmental agencies but also commercial, Medicare Advantage, and Managed Care Organization payers. As with clinical denials, these audits are tedious and can no longer be ignored due to payment recoupments, denial rates increasing audits and extrapolation processes by the payers. 

Apricity Healthcare Solutions, LLC can help relieve the burden these audits cause hospitals by completing and managing the appeals needed for the denial as well as prevent the denial by ensuring that all documentation that proves medical necessity is provided when agencies use pull lists or additional documentation requests (ADR). 

Apricity Healthcare Solutions, LLC provides its contracted clients with reports that help identify opportunities for denials prevention and specific payer denial rates. In addition to this, Apricity Healthcare Solutions, LLC also provides consulting services for its contracted clients which helps dive deeper into the organization’s top denial reasons, diagnoses, and payers. With this information, we work with the organization’s billing, utilization management, case management, and patient access teams to build denial prevention processes into the team’s practices. 

Apricity Healthcare Solutions, LLC will also consult with our contracted clients to provide utilization management guidance on ensuring patients are placed in the correct status. Gone are the days that you allow the payer to guide your patient status by “offering” observation rate of pay for care that was inpatient appropriate. We will share our knowledge and proven strategies for hospitals to support the inpatient status based on payer policies, regulations, and guidelines. 

At Apricity Healthcare Solutions, we know the best offense is a good defense.  Our team of experienced nurses will perform audits on your provider's charts and provide feedback on ways to improve to  ensure compliance with medical necessity and billing requirements.  

Our sister company, Apricity RCM, offers medical billing services for individual and group practices.  Partnering with Apricity Healthcare Solutions, our team can provide unparalleled expertise in billing guidelines, documentation requirements, and appeal processes.