Case Study

Denials Resolution & Prevention

Over $1.2 Million Recovered in Overturned Chemotherapy Drug Claims

The Healthcare System

As a prominent, university-based medical center in the Southeast, the healthcare system provides expertise in more than 100 medical specialties and offers close to 40 outpatient sites. With 1,800 providers and scientists, it is also home to nationally ranked eye, cancer, & cardiac centers.

Challenges

The health system faced a significant challenge when a major payer implemented a new policy requiring certain high-cost chemotherapy drugs to be sourced from specific “specialty pharmacies” approved by the payer.

Unexpected denials of high-cost chemotherapy drugs due to a surprise payer policy
Inconsistent denials justifications and outcomes for recurring patients
Potential disruption to patient care and hospital operations due to drug inavailability

Our Solutions

The solution involved a combination of technical and legal expertise; an intricate comprehension of the legal and practical issues involved; a dogged determination to write effective appeals letters; and persistently pursuing appeals through multiple levels, escalating to the payer’s provider relations team when necessary.

Leveraged Aspirion’s specialized legal and technical expertise
Analysis and research of new policy to identify weaknesses in payer’s arguments
Implemented strategic tracking system to monitor claim status and identify trends
Applied customized appeal strategy to address the payer policy impact on patient care, hospital operations, and contractual obligations

Partnership Powered by Results

Aspirion leveraged its team of specialized attorneys to overturn the claim denials through meticulous documentation, in-depth analysis, and tailored appeals. Their persistent follow-up and continuous strategy refinement distinguished Aspirion’s approach, leading to exceptional recovery results.

Increased Yield

70%

success rate in overturning denials, far exceeding initial expectations

Optimized Collections

$1.2M

recovered in disputed claims due to legal expertise

“Aspirion has been very responsive and flexible. The team of people who we worked with during the implementation was outstanding. We have access to people who can make decisions, and we have regular check-in calls with operational stakeholders. We like the firm to be able to show the key statistics, talk through them, and let us know whether they see an opportunity. That is the approach that Aspirion has shown so far. They collaborate, listen, and are adaptable. They have good people skills and communication, and they are a good partner. Aspirion doesn’t just sell us something for the sake of selling something and charge us for every little thing. They spend time listening to and understanding us. They are transparent about what they cannot do. The partnership has been our highlight with Aspirion.”

Analyst/Coordinator
Aspirion Denials Management Client