Appeals Program

If your institution, like many hospitals across the country, is realizing proactive new measures to insure financial solvency while maintaining and, even, improving patient care, appealing a denial of reimbursement is a requisite opportunity to fuel such changes. Between the need for physician review and time limits to submit, many burdened hospital utilization review staffs have refocused productivity with the unmatched help of RTR’s Hospital Appeals Program.

Our staff is referred accounts on a daily or weekly basis to appeal denials of reimbursement on utilization and administrative grounds. Upon receiving a referral, the collection of all pertinent hospital records, including the payer’s denial, explanation of benefits, the UB-04, and the medical record in question, commences.

Account appeals where utilization grounds suppose reimbursement denial are prepared by physicians, who thoroughly review patient medical records to insure petition relevance. For wrongly denied reimbursements, a physician will write an appeal that rightfully legitimates the clinical rationale for hospitalization through showing how the services rendered were medically necessary and appropriately rendered.

Appeals denied on administrative grounds are prepared by a vetted third-party reimbursement specialist, who evaluates an account to determine if denial reasoning is valid or not valid. Valid appeals are further reviewed to explore if grounds for an appeal, nevertheless, exist. Any administrative appeals will detail the errors in denial or why an administrative oversight is justifiably excusable.

All appeals are submitted by certified mail, return receipt requested, and follow-up for a decision on an appeal is commenced immediately once the time specified by a payer to respond to an appeal has expired.