Appeals

Versalus Health appeals solutions leverage a data-driven, outcomes-focused approach to preserve revenue while optimizing your coding, CDI, case management, and physician advisor teams’ time.

If your organization has an appeals team, we offer appeal solutions that can help you improve or augment in-house capabilities.

We also offer a comprehensive solution that includes clinical and coding case reviews, denial and appeal analysis, peer-to-peer discussion with payer’s medical directors, written appeals, and an expert team of appeals specialists to process your appeals successfully and on time.

 

Denials Management and Recovery

The Versalus Health difference lies in our team and process, underpinned by our robust reporting, workflow, and analysis.

We have expertise with all types of denials, including:

  • Medical necessity
  • Diagnosis-Related Group (DRG) downgrades
  • Level of care
  • Experimental
  • Precertification
  • Probes
  • NCD/LCD
  • Additional denials often overlooked by other vendors

Our Appeals Support Process

The Versalus Health approach to denials utilizes analytics to quantify individual payer performance and develops a differential appeal strategy for private/commercial payers and cases by type. Our denial approach focuses on three pillars:

The Appeal Team

Our seasoned staff has extensive, hands-on experience in all types of appeals. Versalus Health’s experts stay up to date on payer requirements to optimize the appeals process and achieve better results for you. Our clinical team includes HIM professionals, physicians with experience as Medical Directors for insurance companies, nurses, and clinical documentation specialists with utilization management, case management, CDI, and payer experience. In addition, we can act on your behalf to reduce red tape and unnecessary delays, freeing up your staff to focus on other priorities.

The Appeal Process

Versalus Health supports clients by appealing all inappropriate payer denials. We perform all actions related to Medicare and private payer appeals, from evaluating the denial and creating a defense to monitoring the appeal process and following up afterward. For Medicare Fee-for-Service, Versalus Health has extensive experience at all levels of the Medicare appeal process. Versalus Health performs appeals for Medicare Levels 1 (Redetermination), Level 2 (Reconsideration), Level 3 (Administrative Law Judge or ALJ), Level 4 (Department Appeals Board or DAB), and Level 5 (Federal Court Judicial Review). Versalus Health reviews all cases a Medicare contractor denies and provides appeal service and strategic counsel on how to best proceed with each case.

For Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs) reviews, the Versalus Health program includes strategic support and expert advice and outlines the best course of action with BFCC-QIOs. In addition, it provides experts to support clients during the BFCC-QIOs educational meeting.

Versalus Health also has a team of experienced physicians who assist hospitals during an investigation by the Office of Inspector General (OIG) or Department of Justice (DOJ).

The Versalus Health’s team has successfully appealed denials by Quality Improvement Organizations (QIOs), Medicare Administrative Contractors (MACs), and through the Administrative Law Judge (ALJ), Departmental Appeals Board (DAB), and US District Court judicial review.

For commercial/private payer cases, Versalus Health appeals each case to the highest levels available. We document the appeal process and hold the payer accountable to timeliness rules. Versalus Health quantifies and reports the most egregious upheld denial cases, so our clients can use this information in future contract negotiations.

The Platform

Our proprietary platform provides extensive and detailed reporting and analysis. It gives your denials task force the information needed to prevent denials, accurately fight appropriate denials, and identify required contractual changes.

Improve Your Appeal Success Rate

Find out how we can help you improve your Medicare and private-payer appeals. We’ll review your current appeals process and identify strategies for integrating the Versalus Health approach into your existing process.

 

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