The Washington & West Process
Washington & West’s success rate with all denial types, including Medicare Advantage and Medicare MAC/RAC denials, is due to the expertise and team approach applied to each and every denial. Our multidisciplinary team consists of:
- Clinicians (physicians, physician assistants, registered nurses);
- Certified professional coders;
- Reimbursement analysts;
- Recovery specialists;
- Administrative support staff
W&W’s labor-intensive, team oriented approach to each claim is tracked and managed by Quantum Appeals©, proprietary software that provides focused standard, ad-hoc and customizable reporting. Referred claims are electronically uploaded into Quantum Appeals©. The claims are then analyzed to determine the optimal strategy for achieving payment of the claim in the shortest possible time. All applicable due dates for any necessary appeals and the strategy for pursuing a denial overturn are documented in Quantum Appeals, and then tracked through every stage of the recovery/appeals process. Coordination of the workflow is managed by Quantum Appeals© proprietary applications.
Claim denials are prioritized and routed for review based upon three main factors:
- Deadline to meet the appeal due date
- Date of referral of case
- Nature of case
Once an appeal has been drafted, whether the nature of the denial is technical, administrative or medical, an attorney or senior reimbursement analyst reviews the appeal and, if necessary, adds federal, state, or contractual language to the appeal. Upon approval for submission, the appeal is sent to the appropriate payer and the case is assigned to a reimbursement analyst for follows-up to ensure that the appeal is received and addressed by the payer in a timely manner. Each case is continually audited by an attorney or reimbursement analyst to ensure that the appeal process is proceeding appropriately. In the event of an unfavorable decision, Washington & West will continue appealing meritorious cases through the appropriate levels.
Technical and Administrative Review Process
If the nature of the denial is technical or administrative, the claim is referred to an attorney or senior reimbursement analyst. Our attorneys, reimbursement analysts and recovery specialists work collaboratively to analyze the denied claims utilizing relevant state law, federal law and contract terms. Our team will work to draft arguments that show the requirement at issue was met or should not apply based on contractual terms and/or applicable state and federal laws.
Medical Review Process
If it has been determined that a medical review will be necessary in order to appeal the denial decision, the case is referred to a member of our clinical staff (physician, physician assistant or registered nurse). Once a claim is received by the clinical staff, the patient’s medical records are requested and a clinician reviews the records to identify the necessary clinical facts and documentation that offer the greatest possibility for an overturn of the denial. The clinical reviewer drafts an appeal that presents the clinical facts and documentation that support an overturn of the denial and the draft is sent for editing by our professional administrative personnel. For quality assurance purposes, the clinical coordinator, an attorney, or a senior reimbursement analyst reviews all edited draft appeals. Throughout the entirety of the process the clinical coordinator reviews the caseload on a daily basis to ensure that deadlines are being met and that cases are appropriately assigned.
Medical Coding Review Process
Washington & West’s coding analysis practices are not only accurate and up-to-date, but also uniquely incorporate the expertise of our multidisciplinary team. On-site clinical coders meticulously review medical records for documentation of principal and additional diagnoses, co morbid and complicating conditions, and relevant procedures. Coders utilize multiple resources such as the appropriate ICD-9-CM and HCPCS coding guidelines and AHA Coding Clinics to determine the best appeal presentation to support coding decisions. The clinical coder drafts a detailed appeal and the draft is sent for editing by our professional administrative personnel. For quality assurance purposes, the clinical coordinator, an attorney, or a senior reimbursement analyst reviews all edited draft appeals. In the event that we cannot support our client’s coding decision, we supply appropriate feedback.
Qualification of Clinical Reviewers
Washington & West’s onsite clinical staff consists of physicians, physician assistants, nurses, and certified coders who each have multiple years of direct clinical experience that allows them to effectively review each case and elicit pertinent positive and negative findings to support an overturn of the denial. Additionally, all clinical reviewers receive Washington & West’s proprietary advocacy and appeal writing training.
Our clinical reviewers are strong advocates for our clients and the patients themselves. They approach each case from the standpoint that the vast majority of admissions are medically necessary and that the services were provided at the appropriate level of care. As such, our reviewers are similar to investigators – they search the records for the necessary clinical facts and documentation that, based on their experience, they know will offer the greatest possibility for an overturn of the denial. Using their skills in advocacy and appeal writing they draft an appeal that presents the information in the most effective manner.
Washington & West’s clinical reviewers have a unique understanding of how to successfully appeal Medicare, Medicaid, and commercial denials and routinely serve as expert witnesses during Medicare and Medicaid hearings. Our clinical reviewers are knowledgeable regarding commonly used nationally recognized Utilization Management criteria, and are therefore able to specifically challenge insurance denials that are based upon these criteria. Our coders are certified inpatient (CCS) and outpatient (CPC) coders in addition to AHIMA Approved ICD-10-CM/PCS Trainers.