Home
Experience
Client Stories
industry
Healthcare & Life Sciences

Health system needs remedy for inpatient denials and revenue loss

Context

An integrated, multi-state health system generating $4.7B in net patient service revenue faced significant inpatient status denials, creating financial losses and concerns about patient care. Key challenges included a Care Management operating model lacking accountability, weak feedback loops between revenue cycle and clinical teams, and limited collaboration on root cause resolution. What’s more, the absence of customized, actionable reporting hindered issue identification, trend analysis, and process improvement effectiveness.​

Value Created

Reduced inpatient status denials by 70%​
over a 13-month period
Decreased write-offs by 76%
related to medical necessity and level-of-care determinations
Secured $60M in charges
through successful peer-to-peer review reversals
Improved appropriate inpatient status by 10%
enabling accurate reimbursement over the same 13-month period

People

VALUE LEVERS

  1. Leadership and operational ownership
  2. Cross-functional clinical and revenue collaboration
  3. Accountability structure for denials

HOW WE DID IT

  • Placed a Director of Care Management and Manager of Data Analytics in operational roles; partnered with Senior Leadership and secured sponsorship from clinical leadership to drive accountability and execution
  • Integrated Care Management with revenue cycle through cross-functional workgroups and payer-focused Utilization Management meetings; strengthened physician engagement and coaching in peer-to-peer processes
  • Established ownership of denial populations and distributed targeted weekly (operational) and monthly (executive) reports to drive transparency, action, and feedback loops

Process

VALUE LEVERS

  1. Organization redesign
  2. Workflow re-engineering
  3. Data transparency and reporting
  4. Escalation and status optimization

HOW WE DID IT

  • Implemented an onsite physician-facing team, centralized Utilization Management and authorization coordinators, denial appeals team, and analytics support to promote accountability and responsiveness
  • Redesigned peer-to-peer escalation, utilization review, and discharge planning workflows; tracked processes and outcomes for continuous improvement
  • Segmented denial reporting by physician and clinical area; deployed dashboards tracking escalations, completion, and overturn rates; built detailed peer-to-peer reporting by physician
  • Developed a methodology to track and categorize escalations to ensure correct patient status placement (e.g., inpatient upgrades/downgrades)