Challenge

A large, multi-department hospital with more than $1 billion in net patient revenue and over 34,000 discharges annually was
having difficulty managing denials and appeals volume. The hospital’s in-house denials management team believed certain
DRGs were not worth appealing and downgraded them at time of denial.

Solution

Seeking a better way to utilize internal resources and recognizing they could not keep up with the volume of denials, the hospital agreed to pilot Cloudmed Denials Recovery. Cloudmed evaluated 25 cases, which would have been closed by the hospital without appeal, and recovered $293,000. Given the success of the pilot program, Cloudmed became the hospital’s sole denials management vendor. Collaboration on process improvement initiatives with payers and denial identification has eased the burden on staff. Creation of constant feedback loops from Cloudmed to the client team has resulted in improved appeal turnaround timeframes and payer accountability, as well as highlighted areas for denials prevention and clinical feedback.

Results

In the first year, Cloudmed was referred 9,234 cases and recovered $40 million in revenue. By partnering with Cloudmed, the hospital has maximized recoveries and now appeals 100% of denials.