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					  Denial Recovery
      Sample
Service Project Report
                                          EXECUTIVE REVIEW
SCOPE:
The objective is to identify opportunities for financial improvement in order to enhance cash flow and
perform an assessment of collectibles of the current receivables.

APPROACH:

UR Solutions Team applied the following methodology of data gathering to support the observations
contained in this report.
    Account sampling
    Account review and resolutions
    System reports reviewed
    Interaction with business office staff
    Review and analysis

Deliverable Overview:
This document summarizes the observations made by UR Solutions as a result of the day-to-day
operations being conducted as part of the scope of work of the UMMS Denial Recovery Services project.
This sample report focuses on all denials received by UR Solutions from UMMS.

The observations are inclusive of all the denied Accounts Receivable claims assigned to UR Solutions by
UMMS. This sample report contains only 113 cases. A more in-depth executive summary for year ending
2011 shall be available last week in January 2012. After which executive summaries shall be provided on
a quarterly basis. As you can see one day denials has the highest occurrence for denial reasons. Does not
a meet inpatient criterion also has the highest denial reason for medical necessity denials.

The observations are made as a result of the work being conducted to identify recoverable denied
claims, interactions with UMMS staff, interaction with payers and URS’ industry experience. In addition
to providing our observations we offer “Industry Best Practices Recommendations” specific to UMMS
with the assumption that these will be adopted and implemented throughout UMMS healthcare
providers, Patient financial services, Patient access etc.

Denial by Denial Reasons and total charges

Denial by LOS

Denials by month of admission

Denials by payer and total charges

Denials by payers and volume

Denial by services and total charges

Denials by physicians and total charges
                         Value added services and Opportunities

The following items are potential service enhancements that have been identified, which may favorably
impact UMMS’s bottom line.

   1. Observation
            a. Staff (Nurses and Physicians, Including Residents) education on observation
            b. Specific observation order sets
            c. Code 44
            d. Observation and D/C nurse – monitoring all same day to 3 days on inpatient admission
   2. Patient Access
            a. Central registration
            b. Pre-registration process
            c. Pre-authorization process
            d. Registration process
            e. Financial counseling
            f. Scheduling process
            g. Intake process
            h. Direct admission process
   3. Patient Financial Services
            a. Create a bill-hold process on all 0-2 days inpatient admissions
            b. Create a bridge routine
            c. Audit nurse to InterQual all 0-2 days inpatient admission for medical necessity
   4. Utilization Review and CDI specialist
            a. Concurrent reviews in IQ and Milliman care guidelines
            b. CDI specialists for concurrent physician queries
            c. Review records in MR
            d. Review all contracts
   5. Physicians please (do not write “plan to d/c before d/c day – payers will not pay for days after
       this is written)
   6. Review all 835s
   7. Medicare denials needs to be re-visited
   8. Review of contracts and payments from payers to the facility – with write-off amounts
   9. MAP Key indicators: allow a standard approach to measuring revenue cycle performance
            a. UMMS and its affiliates
   10. Units and departments should be educated of methods to prevent denials, and be accountable
       for each denial from their departments
                                   Trend of Denials by Month of Admission

                    Total                       50
Month   Vol         Charges                     45
MAR             1       7,429.02                40
JUN             3      21,435.00                35
JUL            12      61,132.22                30
AUG            19     130,277.50
                                                25
SEP            46     939,945.45                                                              Vol
                                                20
OCT            32     333,295.37
                                                15
Total         113   1,493,514.56
                                                10
                                                 5
                                                 0
                                                      MAR     JUN     JUL   AUG   SEP   OCT




                                    Denials by Admission Month

                                                                                  MAR
                                                                                  JUN
                                                                                  JUL
                                                                                  AUG
                                                                                  SEP
                                                                                  OCT
                                                                 By Denial Reasons
Denial Reason                                                                   Vol          Percent    Total Charges      Percent
Contractual - Charges Exceed Fee Schedule                                               1         0.90%              $0.00      0.00%
Level of Care - Outpatient Procedure                                                    1         0.90%          $9,967.56      0.70%
Medical Necessity - Does not Meet Care Guidelines                                       1         0.90%          $3,618.00      0.20%
Medical Necessity - Does not Meet IP Criteria/Delay in Svc                              1         0.90%          $7,492.70      0.50%
Missing                                                                                 2         1.80%         $19,405.12      1.30%
Authorization & Verification                                                            3         2.70%         $18,014.55      1.20%
Care Delivery Delay - Delay in Surgery/Discharge                                        3         2.70%         $67,206.96      4.50%
Lack of Clinical Information Requested - UR                                             3         2.70%         $15,551.89      1.00%
Care Delivery Delay - Delay in D/C Planning                                             4         3.50%        $105,557.00      7.10%
Care Delivery Delay - Delay in Services                                                 5         4.40%         $24,516.72      1.60%
Medical Necessity - Observation Care                                                    6         5.30%         $19,848.25      1.30%
Level of Care - Lower Level of Care                                                    30        26.50%        $398,494.53     26.70%
Medical Necessity - Does Not Meet IP Criteria                                          54        46.90%        $803,841.28     53.80%
Summary                                                                               113       100.00%     $1,493,514.56     100.00%

            Medical Necessity – Does Not Meet IP Criteria
                       Level of Care – Lower Level of Care
                    Medical Necessity – Observation Care
                   Care Delivery Delay – Delay in Services
               Care Delivery Delay – Delay in D/C Planning
              Lack of Clinical Information Requested – UR
         Care Delivery Delay – Delay in Surgery/Discharge
                                                                                                                                  Vol
                              Authorization & Verification
                                                  Missing
Medical Necessity – Does not Meet IP Criteria/Delay in Svc
      Medical Necessity – Does not Meet Care Guidelines
                     Level of Care – Outpatient Procedure
               Contractual – Charges Exceed Fee Schedule

                                                             0        10       20           30        40        50         60
                         Denied Cases by Length of Stay Days (sorted by volume high to low)


Length of Stay   Vol Percent Total Charges                            Denied Cases by LOS
1 day             52   46.0%  $215,276.60
2 days            14   12.4%    $93,519.95         25 days
3 days             8    7.1%    $60,926.83         24 days
4 days             7    6.2%    $94,074.81         21 days
5 days             5    4.4%    $51,229.17         20 days
6 days             5    4.4%  $121,642.13          19 days
7 days             2    1.8%    $80,444.94         15 days
9 days             1    0.9%    $61,237.81
                                                   14 days
10 days            3    2.7%    $37,748.44
                                                   13 days
11 days            1    0.9%         $0.00
                                                   12 days
12 days            3    2.7%  $128,980.25
13 days            1    0.9%    $34,995.48         11 days
                                                                                                        Vol
14 days            2    1.8%  $246,560.81          10 days
15 days            3    2.7%  $124,292.07           9 days
19 days            1    0.9%    $20,982.00          7 days
20 days            1    0.9%         $0.00          6 days
21 days            2    1.8%    $60,822.71          5 days
24 days            1    0.9%         $0.00
                                                    4 days
25 days            1    0.9%    $60,780.56
                                                    3 days
Summary          113 100.0% $1,493,514.56
                                                    2 days
                                                     1 day

                                                             0   10      20    30      40     50   60
                Denials by Physician (sorted by Physician Name)
Physician                                      Vol         Total Charges
ABRAMS, SARAH                                          2                    $6,811.00
ALBRAT, JOHN                                           1                    $3,618.00
ALI, JUDY                                              1                    $1,591.72
ANJALI, BILAL                                          1                   $11,521.07
BATEMAN, DAVID                                         2                   $40,146.57
BATES, HARRISON                                        1                    $6,053.58
BENDER, JESSE                                          1                    $3,527.02
BENJAMIN, GEORGE                                       1                    $5,298.21
BLANTON, WILSON                                        1                    $3,492.87
BOWMAN, CHRISTOPHER                                    1                    $4,933.42
BRADEN, FREDERICK                                      2                   $84,360.92
BROWN, JIM                                             1                    $2,484.00
BROWN, REGINALD                                        1                   $49,200.78
CANTON, TIM                                            3                   $75,873.40
CHONG, STEPHANIE                                       1                    $7,055.33
CRAWFORD, CARL                                         1                    $6,070.24
CROPE, JOSHUA                                          1                    $1,591.72
CUMMINGS, LYLE                                         1                   $48,555.42
DETMER, REGGIE                                         2                    $8,801.52
DIMBAKA, SAMUEL                                        2                   $43,311.80
DUNBAR, RED                                            1                    $1,458.00
EDWARDS, JOSHUA                                        1                        $0.00
EDWARDS, JOSEPH                                        1                    $6,583.89
FENTON, DANIEL                                         1                   $14,989.60
FRIED, EMMANUEL                                        3                   $10,945.97
GANDER, TYRONE                                         1                    $5,888.21
GETZ, MICHAEL                                          1                   $38,180.35
GIMP, DIANE                                            1                    $1,453.04
GUNDER, ANDREW                                         5                   $26,084.57
GUTTIEREZ, CHRISTOPHER                                 1                        $0.00
HAMILTON, MARK                                         2                   $30,648.89
HANEY, HAROLD                                          1                    $2,786.70
HEMPKIN, MARC                                          2                   $15,085.02
HOPE, CHARITY                                          1                   $11,687.85
HUNT, SHARON                                           1                    $9,967.56
JACOBS, DANIEL                                         3                   $29,004.25
JETT, GEORGE                                           1                    $1,628.00
JEFFERSON, RYAN                                        2                   $12,321.88
JOHNSON, ADAM                                          1                    $2,763.72
JOHNSON, NICHOLAS                                      1                    $7,577.66
KRATER, CINDY             1      $24,223.24
KUMP, BRADLEY             1      $25,380.90
LATE, ROBERT              1      $22,246.44
LAMPOON, WILSON           1       $7,583.58
LEPSON, MATTHEW           1       $7,583.58
LIT, JASON                1       $4,934.35
LUTZ, PEDRO               2       $9,337.62
MENDELHOFF, KEITH         1       $2,563.00
MONROE, BONNIE            2       $9,393.68
NAPEL, FAHAD              1       $2,563.00
NEWMAN, JENEE             1      $28,580.08
NGUYEN, KIMBERLY          2       $2,624.00
OBENDORFER, ELIZABETH     2      $16,996.42
OPAL, ETHAN               1      $72,118.65
PAGHAD, JAY               1    $207,804.48
POWERS, MAX               1      $22,032.12
RANDOLPH, ZACHARY         1       $1,589.43
RINDERS, NICOLE           1      $47,043.71
RITTERS, KAREN            2      $11,763.48
SAMPSON, MARSHALL         1      $20,982.00
SATURDAY, JOSEPH          1           $0.00
SENTEM, TOMMY             1      $55,064.04
SHAMBONE, RUSSEL          1       $2,898.70
SHEETZ, MATTHEW           1       $3,688.38
SHIN, RONALD              1       $8,297.24
SIMPSON, RALPH            1       $7,059.50
SIRIUS, ORBRAE            1       $3,669.43
SOUL, DOMINICK            1       $2,987.40
STAMP, RASHAD             1       $1,458.00
STANTON, MICHAEL          2       $6,576.27
TARP, CHRISTOPHER         1      $11,878.79
TAMBLIN, YVETTE           1      $13,779.00
TIFF, ERIC                3      $12,550.08
TURNER, PAUL              1           $0.00
VOTE, CHEN                2      $10,395.52
VUST, ROSE                1       $8,965.34
WALLACE, ANASTASIS        2      $12,513.15
WATSON, TRACY             1       $1,907.72
WENDEL, CAROLYN           1       $1,454.72
WILSON, SUSANNA           5    $134,770.05
WOLF, DONALD              1       $2,903.72
Summary                 113   $1,493,514.56
                  Denials by Physician & Volume (high to low)
Physician                                      Vol         Total Charges
GUNDER, ANDREW                                         5                    $26,084.57
WILSON, SUSANNA                                        5                   $134,770.05
CANTON, TIM                                            3                    $75,873.40
FRIED, EMMANUEL                                        3                    $10,945.97
JACOBS, DANIEL                                         3                    $29,004.25
TIFF, ERIC                                             3                    $12,550.08
ABRAMS, SARAH                                          2                     $6,811.00
BATEMAN, DAVID                                         2                    $40,146.57
BRADEN, FREDERICK                                      2                    $84,360.92
DETMER, REGGIE                                         2                     $8,801.52
DIMBAKA, SAMUEL                                        2                    $43,311.80
HAMILTON, MARK                                         2                    $30,648.89
HEMPKIN, MARC                                          2                    $15,085.02
JEFFERSON, RYAN                                        2                    $12,321.88
LUTZ, PEDRO                                            2                     $9,337.62
MONROE, BONNIE                                         2                     $9,393.68
NGUYEN, KIMBERLY                                       2                     $2,624.00
OBENDORFER, ELIZABETH                                  2                    $16,996.42
RITTERS, KAREN                                         2                    $11,763.48
STANTON, MICHAEL                                       2                     $6,576.27
VOTE, CHEN                                             2                    $10,395.52
WALLACE, ANASTASIS                                     2                    $12,513.15
ALBRAT, JOHN                                           1                     $3,618.00
ALI, JUDY                                              1                     $1,591.72
ANJALI, BILAL                                          1                    $11,521.07
BATES, HARRISON                                        1                     $6,053.58
BENDER, JESSE                                          1                     $3,527.02
BENJAMIN, GEORGE                                       1                     $5,298.21
BLANTON, WILSON                                        1                     $3,492.87
BOWMAN, CHRISTOPHER                                    1                     $4,933.42
BROWN, JIM                                             1                     $2,484.00
BROWN, REGINALD                                        1                    $49,200.78
CHONG, STEPHANIE                                       1                     $7,055.33
CRAWFORD, CARL                                         1                     $6,070.24
CROPE, JOSHUA                                          1                     $1,591.72
CUMMINGS, LYLE                                         1                    $48,555.42
DUNBAR, RED                                            1                     $1,458.00
EDWARDS, JOSHUA                                        1                         $0.00
EDWARDS, JOSEPH                                        1                     $6,583.89
FENTON, DANIEL                                         1                    $14,989.60
GANDER, TYRONE             1       $5,888.21
GETZ, MICHAEL              1      $38,180.35
GIMP, DIANE                1       $1,453.04
GUTTIEREZ, CHRISTOPHER     1           $0.00
HANEY, HAROLD              1       $2,786.70
HOPE, CHARITY              1      $11,687.85
HUNT, SHARON               1       $9,967.56
JETT, GEORGE               1       $1,628.00
JOHNSON, ADAM              1       $2,763.72
JOHNSON, NICHOLAS          1       $7,577.66
KRATER, CINDY              1      $24,223.24
KUMP, BRADLEY              1      $25,380.90
LATE, ROBERT               1      $22,246.44
LAMPOON, WILSON            1       $7,583.58
LEPSON, MATTHEW            1       $7,583.58
LIT, JASON                 1       $4,934.35
MENDELHOFF, KEITH          1       $2,563.00
NAPEL, FAHAD               1       $2,563.00
NEWMAN, JENEE              1      $28,580.08
OPAL, ETHAN                1      $72,118.65
PAGHAD, JAY                1    $207,804.48
POWERS, MAX                1      $22,032.12
RANDOLPH, ZACHARY          1       $1,589.43
RINDERS, NICOLE            1      $47,043.71
SAMPSON, MARSHALL          1      $20,982.00
SATURDAY, JOSEPH           1           $0.00
SENTEM, TOMMY              1      $55,064.04
SHAMBONE, RUSSEL           1       $2,898.70
SHEETZ, MATTHEW            1       $3,688.38
SHIN, RONALD               1       $8,297.24
SIMPSON, RALPH             1       $7,059.50
SIRIUS, ORBRAE             1       $3,669.43
SOUL, DOMINICK             1       $2,987.40
STAMP, RASHAD              1       $1,458.00
TARP, CHRISTOPHER          1      $11,878.79
TAMBLIN, YVETTE            1      $13,779.00
TURNER, PAUL               1           $0.00
VUST, ROSE                 1       $8,965.34
WATSON, TRACY              1       $1,907.72
WENDEL, CAROLYN            1       $1,454.72
WOLF, DONALD               1       $2,903.72
Summary                  113   $1,493,514.56
               Denials by Physician & Total Charges (high to low)
Physician                                      Vol         Total Charges
PAGHAD, JAY                                            1                   $207,804.48
WILSON, SUSANNA                                        5                   $134,770.05
BRADEN, FREDERICK                                      2                    $84,360.92
CANTON, TIM                                            3                    $75,873.40
OPAL, ETHAN                                            1                    $72,118.65
SENTEM, TOMMY                                          1                    $55,064.04
BROWN, REGINALD                                        1                    $49,200.78
CUMMINGS, LYLE                                         1                    $48,555.42
RINDERS, NICOLE                                        1                    $47,043.71
DIMBAKA, SAMUEL                                        2                    $43,311.80
BATEMAN, DAVID                                         2                    $40,146.57
GETZ, MICHAEL                                          1                    $38,180.35
HAMILTON, MARK                                         2                    $30,648.89
JACOBS, DANIEL                                         3                    $29,004.25
NEWMAN, JENEE                                          1                    $28,580.08
GUNDER, ANDREW                                         5                    $26,084.57
KUMP, BRADLEY                                          1                    $25,380.90
KRATER, CINDY                                          1                    $24,223.24
LATE, ROBERT                                           1                    $22,246.44
POWERS, MAX                                            1                    $22,032.12
SAMPSON, MARSHALL                                      1                    $20,982.00
OBENDORFER, ELIZABETH                                  2                    $16,996.42
HEMPKIN, MARC                                          2                    $15,085.02
FENTON, DANIEL                                         1                    $14,989.60
TAMBLIN, YVETTE                                        1                    $13,779.00
TIFF, ERIC                                             3                    $12,550.08
WALLACE, ANASTASIS                                     2                    $12,513.15
JEFFERSON, RYAN                                        2                    $12,321.88
TARP, CHRISTOPHER                                      1                    $11,878.79
RITTERS, KAREN                                         2                    $11,763.48
HOPE, CHARITY                                          1                    $11,687.85
ANJALI, BILAL                                          1                    $11,521.07
FRIED, EMMANUEL                                        3                    $10,945.97
VOTE, CHEN                                             2                    $10,395.52
HUNT, SHARON                                           1                     $9,967.56
MONROE, BONNIE                                         2                     $9,393.68
LUTZ, PEDRO                                            2                     $9,337.62
VUST, ROSE                                             1                     $8,965.34
DETMER, REGGIE                                         2                     $8,801.52
SHIN, RONALD                                           1                     $8,297.24
LAMPOON, WILSON            1       $7,583.58
LEPSON, MATTHEW            1       $7,583.58
JOHNSON, NICHOLAS          1       $7,577.66
SIMPSON, RALPH             1       $7,059.50
CHONG, STEPHANIE           1       $7,055.33
ABRAMS, SARAH              2       $6,811.00
EDWARDS, JOSEPH            1       $6,583.89
STANTON, MICHAEL           2       $6,576.27
CRAWFORD, CARL             1       $6,070.24
BATES, HARRISON            1       $6,053.58
GANDER, TYRONE             1       $5,888.21
BENJAMIN, GEORGE           1       $5,298.21
LIT, JASON                 1       $4,934.35
BOWMAN, CHRISTOPHER        1       $4,933.42
SHEETZ, MATTHEW            1       $3,688.38
SIRIUS, ORBRAE             1       $3,669.43
ALBRAT, JOHN               1       $3,618.00
BENDER, JESSE              1       $3,527.02
BLANTON, WILSON            1       $3,492.87
SOUL, DOMINICK             1       $2,987.40
WOLF, DONALD               1       $2,903.72
SHAMBONE, RUSSEL           1       $2,898.70
HANEY, HAROLD              1       $2,786.70
JOHNSON, ADAM              1       $2,763.72
NGUYEN, KIMBERLY           2       $2,624.00
MENDELHOFF, KEITH          1       $2,563.00
NAPEL, FAHAD               1       $2,563.00
BROWN, JIM                 1       $2,484.00
WATSON, TRACY              1       $1,907.72
JETT, GEORGE               1       $1,628.00
ALI, JUDY                  1       $1,591.72
CROPE, JOSHUA              1       $1,591.72
RANDOLPH, ZACHARY          1       $1,589.43
DUNBAR, RED                1       $1,458.00
STAMP, RASHAD              1       $1,458.00
WENDEL, CAROLYN            1       $1,454.72
GIMP, DIANE                1       $1,453.04
EDWARDS, JOSHUA            1           $0.00
GUTTIEREZ, CHRISTOPHER     1           $0.00
SATURDAY, JOSEPH           1           $0.00
TURNER, PAUL               1           $0.00
Summary                  113   $1,493,514.56

				
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