Partnership Powered by Results
$55M+
recovered from medical necessity denials with clinical review team + attorneys
$42M+
recovered from medical necessity denials disguised as authorization denials
50%+
success rate for readmission denials and $6M+ recovered
RESULT
Exceptional Medical Necessity Recovery:
- Recovered $55M+ from medical necessity denials using Aspirion’s clinical review team and dedicated legal expertise
Hidden Revenue Discovery:
- Uncovered $42M+ in recoveries for medical necessity denials disguised as authorization-related denials
Readmission Recovery Success:
- Achieved $6M+ in readmission denial recoveries with over 50% success rate
CHALLENGE
Complex Medical Necessity Landscape:
- Inpatient medical-necessity denials represented over 90% of all medical necessity denials with average 4-day length of stay
Level of Care Disputes:
- High volume of inpatient level of care denials for 2-4 day stays, where payers demanded observation-level billing instead
Escalating Readmission Pressure:
- Readmission denials skyrocketed over 500% from 2022 to 2024, creating unprecedented revenue risk
SOLUTION
Aspirion deployed a multi-pronged strategy combining clinical expertise with legal precision:
Strategic Case Assessment:
- Identified weak cases for potential inpatient-to-observation claim corrections using CMS and payer guidelines while ensuring timely filing
Clinical-Legal Integration:
- Leveraged Aspirion nurse review team to strengthen attorney-filed appeals with clinical documentation
Regulatory Expertise:
- Applied state-specific statutes in appeals process when carriers denied authorized inpatient services for medical necessity
“Aspirion is timely. They have great customer service, and they are staffed well with competent people. Aspirion has online attorneys too, so that makes the processing of claims go a lot faster. Also, the firm is very patient friendly and hospital friendly.”
About the Provider
- Leading not-for-profit community health system serving the Midwest
- Encompasses 200+ care locations across primary, urgent, pediatric, cancer and specialty services, plus 14 hospitals
- National leader in patient experience