Medical Necessity and Clinical Denial Appeals Management
Inpatient Level of Care Appeals
Outpatient Medical Necessity Appeals
Outpatient Medical Necessity Appeals
Payers are increasingly denying inpatient level of care cases, forcing the Utilization Management team to either downgrade the patient to outpatient (observation) status or add to their workload and fight for the inpatient status they know is correct.
Appealing an inpatient level of care denial is tedious and requires knowledge of medical
Payers are increasingly denying inpatient level of care cases, forcing the Utilization Management team to either downgrade the patient to outpatient (observation) status or add to their workload and fight for the inpatient status they know is correct.
Appealing an inpatient level of care denial is tedious and requires knowledge of medical complexity, payer rules, regulations, and billing practices. If your appeals team misses one step, the best appeal can be denied on technicalities. Likewise, a poorly written or rushed appeal that doesn't fully explain the complextity of the patient is unlikely to overturn the denial.
Our team of expert RN Appeals Specialists will review each denied case and write a unique appeal to support the need for inpatient stay. Apricity understands that your team is busy with patient care so we handle writing and submitting the appeal, payer follow-up, and tracking for payment.
Outpatient Medical Necessity Appeals
Outpatient Medical Necessity Appeals
Outpatient Medical Necessity Appeals
Outpatient medical necessity denials encompass observation services, outpatient surgeries, diagnostic testing, infusions, therapies and extended outpatient encounters.
Payers, particularly Medicare Advantage plans, are intensifying thier review of outpatient claims and increasing denials even when care aligns with accepted clinical stand
Outpatient medical necessity denials encompass observation services, outpatient surgeries, diagnostic testing, infusions, therapies and extended outpatient encounters.
Payers, particularly Medicare Advantage plans, are intensifying thier review of outpatient claims and increasing denials even when care aligns with accepted clinical standards.
Outpatient denials are especially costly because of the high volume of services with slim margins.
Our team performs deep clinical reviews and align our appeals with payer-specific criteria and evidence-based care practices. As with all appeals we work, Apricity will write and submit the appeal, complete all payer follow-up, and track the claim for payment.
No Authorization Appeals
Outpatient Medical Necessity Appeals
No Authorization Appeals
Hospitals often mistakenly believe denials due to no prior authorization are not winnable and write off these high dollar claims.
Apricity takes a different approach to these claims. Our proprietary processes ensure these denied claims get the attention they deserve. We focus on recovering payment for denied services when authorization
Hospitals often mistakenly believe denials due to no prior authorization are not winnable and write off these high dollar claims.
Apricity takes a different approach to these claims. Our proprietary processes ensure these denied claims get the attention they deserve. We focus on recovering payment for denied services when authorization was missed, delayed or improperly applied. Our clinical and regulatory experts conduct detailed reviews of payer policies and authorization requirements and build complelling appeal narratives supported by documentation, timelines, clinical rationale, and regulatory and contractual requirements.