An Additional Layer of Validation Beyond Traditional Claims Scrubbers
Denials Predictor fills the gap left by claims scrubbers. A module within the MDaudit Platform, it helps healthcare organizations get paid on initial claim submissions, avoiding costly appeals and write-offs while giving revenue integrity professionals the power to proactively identify and resolve claims likely to result in denials or delays prior to payer adjudication.
Direct Benefits to Using Denials Predictor
Detailed insights into denial sources to create actionable corrective plans
Prevention of denials before they occur
Boost first pass yield rates
Improved cash flow across the entire organization
How Denials Predictor Works
The Denials Predictor pulls pre-payment charges (both pre-bill and non-adjudicated charges) and applies clinical and financial surveillance rules to provide final claims validation before claims submission or payment, while leveraging a powerful payer-centric rules engine based on a nationwide payer base. Through these rule sets, the module provides an additional layer of identification for denial categories not picked up by traditional claims scrubbers, providing greater insights into the costliest sources of denials.
Rule Groups
Rule Groups illustrate why claims are likely to be denied, whereas claim scrubbers would miss these issues. While these may represent just 10-20% of claims volume, they could account for up to 80% of denial dollars.
Workflow
This explains each denial risk at the charge line level, with payer-specific rules and explanations using the proprietary rules engine. From the dashboard view, lists can be exported as a spreadsheet for distribution or drilled down to view claim detail, which provides full visibility into how to “fix” the charges before submitting them to the payers. If the charges have been recently submitted and have not been paid, you have the ability to re-bill those high-value claims and recover payments quickly. It also provides seamless integration into the audit workflow, so affected charges can be routed to revenue integrity professionals for immediate audit and education to fix systemic issues.
Claim or Pre-Payment Charge Detail
This provides granular detail of the denial risk and the opportunity to proactively make changes before the claim is submitted to the payer. Pre-payment denial insights can seamlessly (and in real-time) be disseminated to those responsible for fixing and building claims edits to ensure revenue recognition and protection.
Proven Outcomes
Results from customers who have successfully transformed their revenue integrity organizations.
Projected Annual Savings
$8M - $10M
A customer has a team of 37,000 employees, providers, and volunteers who deliver care across more than 400 sites. The customer leveraged our RI suite to address denials related to DME devices for cardiology from specific manufacturers that were missing clinical trial numbers and documentation for reimbursements. Their pharmacy teams are also working to address denials related to specialty drugs that have been flagged for biosimilars and orphan drug use.
Projected Annual Savings
$3M - $5M
A customer has a team of 750+ providers across 120 locations with more than a million and a half annual patient visits yearly. The customer leveraged the RI suite to address medical necessity-related denials with knee injections and spinal cord simulators-related claims in their ASC’s and Hospital OP segment from Medicare and RAC’s that were missing clinical documentation justifying treatment paths.
