Case Study

Denials Management

$1M+ in Hidden Revenue Recovery—Strategic Appeals Process Overcomes Payer Auto-Denial Strategy
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EXPERT IDENTIFICATION

$1M+

recovered from previously unappealed denials that internal team classified “weak”

APPEAL MASTERY

75%

appeal overturn rate on “neutral” clinical cases, showing high repayment potential

PRECISION APPROACH

55%

recovery just from overturned claims designated as “neutral”

RESULT

Major Recovery from Written-Off Claims:

  • Recovered $1M+ from previously denials not appealed that health system’s internal team had classified as “weak” with zero appeal attempts

Exceptional Success on Borderline Cases:

  • Achieved 75% appeal overturn rate on “neutral” clinical cases, demonstrating high reimbursement potential when strategic appeals are pursued

Significant ROI on Systematic Approach:

  • Generated 55% recovery from overturned “neutral” claims alone, proving strategic clinical appeal process unlocks hidden revenue across entire denial spectrum

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

Operational Bandwith Strain:

  • A pronounced spike in denials, combined with limited resources, led to write-offs of “weak” downgrade cases—leaving potentially recoverable revenue on the table

SOLUTION

Aspirion deployed targeted expertise to pursue previously abandoned denials:

Strategic Case Recovery:

  • Engaged Safety Net/Large Balance Denials team to appeal “weak” cases through payer’s dispute process using legal and clinical expertise

Clinical Assessment Integration:

  • Leveraged Aspirion Utilization Review team to conduct comprehensive clinical reviews of denied claims

Data-Driven Appeals Strategy:

  • Applied systematic approach to cases deemed “neutral” by internal clinical criteria, revealing high recovery potential even for borderline cases

“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.”

VP/Other Executive
Denials Management Client

About the Provider

  • Leading not-for-profit community health system serving the Mountain West
  • Ranked among the best hospitals in the country, this health system encompasses 200+ care locations with multiple specialties, plus 14 acute-care hospitals