Analytics to Prioritize Denials Recovery Efforts

by XSOLIS Insights, on Feb 25, 2019 6:00:00 AM

“What can we do to shore up processes and optimize outcomes during revenue recovery?”

Our team gets this question time and again. While the first step is deploying technology and analytics, this often proves problematic for many organizations: analytics may not be available, there’s a lack of data flow between solutions, spreadsheet tracking is commonplace. To alleviate this problem and expedite the recovery of revenue lost due to inappropriate medical necessity denials, XSOLIS introduced the XSOLIS Automated Case Triage (XACT) solution.

XACT approaches retrospective review in two distinct ways: first, we assess your denied claims with our proprietary machine learning – and then prioritize them by the probability of inpatient vs. outpatient - a “revenue recoup radar” for the clinical merit of each case. The comprehensive analytics report can then be used by your internal team or our in-house Denials Management team to initiate appeal and recovery efforts. The second approach involves outpatient cases – XACT also employs machine learning to sift through discharged outpatient cases for those that could have been potential inpatient conversions. This serves as an invaluable education and assessment tool to identify trends and mitigate them for the future.

The results can be astounding, especially for providers looking to prioritize appeals in a new way. No longer should hospitals prioritize denials based on date or dollar amount; rather, they should pursue the cases with the highest clinical merit while rethinking those without a strong basis for appeal. XACT paves the way for data-driven review and recovery.

This post was adapted from our recent white paper, "Unpacking the State of Utilization Management 2019." To learn more about the trends shaping the industry, download here.

Topics:Industry Insights