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 due to untimely notification Benefit: Recovery of $68,045.47 A hospital called the payer to notify them of an emergent inpatient admission. The payer stated the case was started and was pending clinical. Later, the claim was denied, due to untimely notification. The hospital was able to retrieve the phone call documenting and proving the date and time of notification. The payer agreed to pay the claim.
Communication Event: VoiCert Challenge: Denial for lack of clinical Benefit: Recovery of $380,000 The hospital used TRACE to record a request for inpatient certification for a continued stay. The payer responded with a voicemail certifying the patient without clinical information based on DRG reimbursement. When the payer called back to rescind the approval, the hospital referenced the recording. Based on this record and without a lengthy retrospective review, the payer honored the verbal approval and overturned the claim for $380,000.
Communication Event: VoiCert Challenge: Denied for Lack of Medical Necessity Benefit: Recovery of $1,165,144.16 A patient was admitted to City of Hope in March 2006 and diagnosed with an acute terminal illness. The hospital used TRACE to record a notification of admission to the patient’s insurance company. A concurrent review was provided in April, and the payer responded that all days were approved. In June, the patient passed away. The next month, the billing office received a denial from the patient’s insurance company. The payer’s case manager stated that City of Hope did not provide sufficient clinical detail, denying the claim for lack of medical necessity. Along with evidence of 36 clinical reviews provided over a 92-day period, City of Hope sent transcripts of the calls to the insurance company. The payer overturned the denial with approval for the entire length of stay, in part due to the evidence captured by telephone using TRACE. The hospital recovered $1,165,144.16 in charges as a result. “We know that sharing the TRACE transcripts of conversations between City of Hope and the payer played a significant role in helping us overturn this denial,” stated case management director Anne Tanner.
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.
Communication Event: FaxCert Challenge: Denial for Lack of Authorization Benefit: Recovery of $43,269.69 A utilization management coordinator initiated a FaxCert to fax a clinical review to an insurance company. The claim was processed, and payment was denied for lack of authorization. The coordinator used TRACE to locate the original fax and resend it to the payer, along with confirmation of the date and time it was originally sent to the insurance company. After reviewing TRACE documentation showing the date and time of the original fax, the payer overturned the denial and reprocessed the claim for payment. 
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