How XSOLIS' Denial Resolution Services Recovered a 700% Return on a Single Claim

Colquitt Regional Medical Center, St. Moultrie, GA

Colquitt_Hospital-Profile

XSOLIS has proven that they can take our most challenging denials and turn them into recoveries

-Mike Wyche, Revenue Management Supervisor

Challenge

CRMC was initially denied $3,165.24 of an $8,689.24 by a national payer after a third-party DRG audit. Then a Part B claim for $2,188.80 resulted in a full takeback of the $8,689.24 claim.

Solution

XSOLIS’ Denial Resolution Services team identified a misfiled claim and worked with the client to recover the full amount nearly three years after it had been written off.

Results

As anyone within healthcare revenue cycle management soon discovers, the intersection between payer, providers, and vendors is a junction fraught with uncertainty. Providers face the unique challenge of providing care while simultaneously navigating the review process to ensure they receive and retain proper revenue for their services. Differences in regulation, variations in services provided, claim age, hospital, and systems in place pose barriers to this process, hampering successful resolution and reimbursement.

In April 2015, Colquitt Regional Medical Center (CRMC), a 151-bed general medical and surgical hospital in Moultrie, GA, submitted an initially straightforward inpatient claim to a national payer, receiving $8,689.24 for services rendered. However, after a DRG audit conducted in December 2015 by a third-party vendor, partial recoupment resulted in a takeback of $3,165.24, leaving Colquitt with a payment of $5,524.00.

CRMC appealed this, but the DRG change was upheld by the vendor. The facility then submitted a claim for Part B charges only, amounting to $2,188.80. By submitting this claim, a full takeback of the previously paid amount on the inpatient claim of $5,524.00 occurred on March 22, 2017, and payment for the Part B charges only was paid in the amount of $618.41.

CRMC first engaged the XSOLIS team in April 2017 to supplement their current denial management process. Understanding that no two patients are the same, XSOLIS takes a unique, intimate approach to denials management by not only building relationships and establishing lines of communication between payers and providers but also selectively choosing appeals based on clinical merit rather than the typical canned reporting and appeals approach. XSOLIS’ expert Denial Resolution team identified the Part B portion of this particular claim as erroneous and immediately began the reconsideration process with the payer in May of 2017.

After submitting an initial reconsideration request to the recovery services department with all clinically pertinent medical records, the payer conducted a full review on the original Part A inpatient claim. A full 845 days after the initial claim submission, this review resulted in a payment of the original amount of $8,689.24.

An effective denials management process requires working the right cases at the right time by the right people. XSOLIS employs a creative approach, analyzing every angle possible for resolution, and conducts dogmatic and persistent follow-up correspondence with payers to ensure you retain or regain the greatest possible revenue. We also seek to empower staff in denial mitigation efforts through a consultative advisory role – ongoing communication and continued case feedback lay the foundation for fewer denial events, now and in the future.

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