NYX Health offers a full range of Utilization Management consulting services to optimize denials and appeal success rates for its hospitals. Its services include concurrent compliance reviews, concurrent denial peer-to-peer reviews with payer Medical Directors, review and appeal of denials based on retrospective written appeals for commercial, managed care, Medicare and Medicaid denials, secondary claims management, and representation at Administrative Law Judge Hearings. In addition, NYX employs up-to-date medical literature as well as coding clinical validation guidelines to assist in reversing denials and improving revenue recovery. NYX Health is staffed to become a leading Utilization Management provider to Healthcare facilities by providing quality services at competitive prices.
NYX offers a full range of compliance and appeals services to hospitals. Our staff consists of experienced US-based physicians, administrative and IT professionals with experience in the following areas:
- Concurrent compliance reviews
- Concurrent Denial Peer to Peer reviews
- Appeals process
- Inpatient, observation, and outpatient procedures
- Psychiatric services
- Inpatient rehabilitation
- Long-term acute care
- Coding and Clinical Validation reviews
- Administrative Law Judge Hearings
- Medicare and Medicaid compliance
- Milliman Care guidelines
Concurrent Compliance Reviews
Upon admission to the hospital, the case manager (CM) runs the clinical data against MCG/InterQual criteria. If it does not meet MCG/InterQual, the CM will send the case to NYX. We will run the case through its “proprietary logic” to make a determination on if the patient should be admitted to an inpatient level of care or an outpatient or “observation” level of care.
In some cases, depending on the length of admission, a continued stay review is warranted to determine if inpatient admission is still appropriate or if the patient is better suited for a non-acute level of care.
Concurrent Denial Peer to Peer Reviews
Following an initial denial of authorization of services, NYX will have the opportunity to speak with a medical director from the payer and schedule a peer-to-peer (P2P) conversation. Many hospitals contract this service with NYX, as it is not cost-efficient to have the attending physician take the time to make these calls.
Commercial and Government Medical Necessity Appeals
After an initial utilization review and P2P, the appeals process is initiated for the hospital. NYX generates and submits written appeals for first level, second level, and external appeals. NYX first evaluates a case for compliance-related issues before constructing a letter summarizing the admission and the reasons why it was medically necessary. Included in the summary is an argument from recent medical literature to support the appeal.
NYX also performs appeals for outpatient procedures (using local and national coverage determinations), psychiatric appeals, observation appeals, obstetrics and NICU, and inpatient rehabilitation appeals (provided the case meets Code of Federal Regulations criteria).
Denial management is labor-intensive and time-consuming. Furthermore, resolving claim denials requires a significant amount of experience and data management to track, correct and re-submit claims for appropriate payment. Lost denials and failure to meet timely filing deadlines exacerbate the problem, and many hospitals write off millions every year unnecessarily. Efficient denial management—and denial prevention—requires specific processes and methods, preferably driven by technology.
NYX maintains a staff of denial management experts that are accustomed to researching and resolving claims-related issues to accelerate payment. Vital to efficiently resolving claims is the use of technology to sort claims by denial types, including eligibility, documentation, coding, duplicate claims, or medical necessity edits. Once sorted, the claims will be automatically routed to the appropriate resource for correction and resubmission, eliminating manual work flow. NYX’s technology provides robust reporting and analysis tools that will allow your hospitals staff to identify root causes and other trends by payer, provider, facility, and more. This information can be used to isolate issues that can be corrected to prevent future denials.
Secondary Claims Management
Secondary claims often have a low-dollar value and many hospitals forego the extra effort required to prepare and submit them. Hospital staff members are often overwhelmed with the volume of higher dollar primary claims, and simply don’t have the bandwidth to cover secondary claims. The secondary claim creation and submission processes can be completely outsourced to NYX so the hospital no longer has to devote critical staff members to this function. NYX’s dedicated staff of secondary claim specialists enables hospitals to focus their resources on other departments— making low-dollar claims worth the effort. Payer follow-up and payment posting are included in our services to further alleviate the burdens on hospital in-house resources. NYX offers technology as part of the engagement, including automation that can benefit your in-house staff working primary claims, as well. The end result is a collectively significant revenue stream that contributes to the bottom line.
Clinical Documentation Improvement Services
Many denials are the result of poor documentation which does not support medical necessity, level of care, and correct coding. We will analyze and identify areas where clinical documentation can be improved and work with your facility to implement a clinical documentation improvement plan.
Our services include:
- Physician engagement and education,
- Collaboration between UM professionals, coding professionals, and providers,
- Implementation of Provider-friendly CDI plan which will decrease denial rate and increase appeal success rate
Administrative Law Judge Hearings
After the written appeals process has been exhausted, the hospital may elect to move forward to an Administrative Law Judge (ALJ) hearing. They make this decision based on our recommendations.
At an ALJ hearing (conducted telephonically), NYX physician advisors act as medical experts to present the case to the administrative law judge. Commercial and managed care payers would be present at the hearing and also bring their own expert witnesses. Medicare hearings, however, do not have a representative attend the hearing.
Most cases do not go past the ALJ level. However, if the ALJ response shows that there is good cause to move forward (judge was biased, misunderstood, or there was a regulatory reason) the next step would be a Departmental of Appeals Board (DAB) appeal.
Coding and Clinical Validation
NYX appeals cases in which primary or secondary codes are denied or when the Diagnosis Related Group (DRG) was denied as not clinically validated. These types of denials have recently become more prevalent. Our team of coders and nurses review medical records to assist in supporting the billed diagnosis. We utilize clinical expertise, physician queries, and the most up-to-date coding regulations to maintain compliance. Some coding cases also proceed to ALJ appeal.
Physician Documentation Optimization
Recurring evaluations of physician documentation supports accuracy, integrity, and quality of patient data while improving physician documentation habits. After review of medical records, NYX will recommend if a physician query is needed. A physician query is initiated for any findings of incomplete, conflicting, and/or ambiguous documentation in the medical record. Clarification of this documentation and front-end corrections are important to support accurate billing and limiting denials.
On-site Physician Advisor Services
NYX provides physicians to remain on-site at hospitals to perform similar duties as listed above. The physician is a NYX employee, but is available on-site to develop closer relationships with hospital staff and become more intimately involved in a specific hospital system rather than consulting for multiple different clients.
Data Analysis Capabilities:
Evaluation of ED discharge and hospital admission data to identify trends which have the potential to prevent denials, maintain better compliance, and support successful appeals. Evaluation of historical claims data to identify specific denial reasons as related to clinical, coding, administrative, documentation issues.
Potential trends include:
- ED treats and releases patients that may have been more appropriate for observation status.
- Observation admissions that may have been more appropriate for IP status.
- Observation and IP status that were changed after admission.
- Potential condition code 44 cases.
- Status correlations with diagnosis codes, lengths of stay, admitting attending, etc.
- Administrative errors (timing of signed order, no signature, illegibility, etc.).
- Poor documentation by diagnosis and by attending leading to improper denials.
- Coding errors and inconsistencies.