Financial Success
Below are "Proof Points" from TRACE customers who have used the power of proof to achieve financial success for their hospitals. See the following examples to learn the benefits of tracking all communication events with TRACE.
Proof Points
Communication Event: VoiCert Challenge: Denial for lack of authorization Benefit: $584.22 A patient access representative at Memorial Hermann Northwest used TRACE to record a call to obtain authorization for an observation stay. The payer responded by stating that observation does not require authorization. The payer later denied the claim for lack of authorization. The hospital submitted a transcript of the call record with an appeal. The denial was overturned, and the hospital recovered $584.22 of the claim for $1,751.75.
Communication Event: Trace Voice Challenge: Denial for lack of precert Benefit: Recovery of $800 A Patient Access representative used Trace to record a call to a payer to request precert for an outpatient diagnostic procedure. The payer verified patient benefits, stating that the procedure was covered 100% for an in-network hospital, with no copay or deductible. The payer also stated that no precert was required for the procedure. The claim was later processed and denied for lack of precert. The hospital used a transcript of the Trace call record to verify that the hospital was told no precert was required. The payer overturned the denial, and the hospital recovered $811.00.
Communication Event: VoiCert Challenge: Denial for 8-day inpatient surgery Benefit: Recovery of $260,068.00 A payer denied coverage for an 8-day inpatient surgery, claiming that the hospital did not provide a referral or obtain authorization for the initial consult and work-up, which included expensive diagnostic testing. From a clinical perspective, the hospital had to proceed with timely surgery in order to avoid detriment to the patient’s well-being. The patient access department used TRACE to locate the call recording, including confirmation of the payer’s authorization for the initial consult and work-up and references to the specific CPT codes. When the department offered to send a transcript of the call, the payer came through with authorization for all services. Without proof of the authorization, the hospital would have had to write off $260,068 in fees for the consult, work-up, surgery and hospital stay.
Communication Event: VoiCert Challenge: Denial for auth not matching billed service Benefit: Recovery of $13,084.25 A patient access representative in the business office used TRACE to record a call placed to obtain benefits for a 23-hour observation stay. The payer responded by issuing authorization for a 23-hour observation visit and advised the hospital to call back if the patient’s status changed to inpatient. The claim was processed and denied on the basis of authorization not matching billed services. The hospital located the TRACE call record and submitted the proof with the appeal. The denial was overturned, and the claim was paid. As a result, Memorial Hermann recovered $13,084.25 of the $21,612 claim.
Communication Event: VoiCert Challenge: Denied for Lack of Clinical Data Benefit: Recovery of $16,812.83 A patient was admitted to the City of Hope Cancer Center. The physician dictated a history and physical for only the first day of the patient’s stay. On the second day, further testing led the physician to write orders for a specific diet. The hospital requested 24 hours to make sure the patient responded well to the treatment. The payer approved the request but later denied the claim, citing “lack of clinical data.” The case manager used TRACE to locate the VoiCert record of the payer’s approval, as well as the supporting clinical data including X-rays, labs and notes. The payer overturned the denial in one day, and the hospital recovered $16,812.83 in charges.
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