Effectively Manage Appeals
Without Adding to Overhead Costs
Medical necessity denials and appeals are the bane of many organizations. Even if they only comprise a small percentage of total services, denials and appeals can impact cash flow and jam up an otherwise smooth revenue cycle management process. Recouping even a small percentage of those dollars can significantly impact the bottom-line.
Whether your organization is undergoing a revenue cycle management assessment, re-evaluating operations, or just looking to capture every possible dollar, HQSI can work with you to reduce the administrative and financial burden. HQSI can efficiently and effectively handle your retrospective medical necessity denials and appeals – without adding to overhead costs.
HQSI’s U.S. based network of Board-certified physicians and credentialed health professionals will efficiently meet your needs, within your budget. HQSI reviewers use evidence-based criteria and current professional standards to make the right decision the first time, every time and produce a high quality, sound determination in every case.
Our physician network covers a diverse and wide range of specialties. Their decision/determinations are always clear, succinct, and valid. We use a secure, web-based system that makes it easy to submit files, track status, and access decisions/determinations at your convenience.
Our experienced staff, history as a Quality Improvement Organization, and current status as a URAC-accredited IRO and a QIO-like entity demonstrate our reliability and service commitment. With HQSI, you get a trusted partner who will maintain quality and save you time, resources and money.
Whether you have an ongoing or just an occasional case need, we can partner with you.
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Medical Necessity or Medically Necessary is defined as treatment for a particular condition to be required and appropriate in accordance with acceptable standards of medical practice and is performed, prescribed or directed by a provider for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are consistent with standard of care in the community and/or supported by evidence based scientific literature or standards published by nationally recognized experts and organizations generally constitute Medical Necessity.
These reviews may involve complex diagnoses; progressive conditions; and terminal illnesses. The reviews require an expert opinion using an evidence-based approach related to experimental or investigational treatments. Cases are generally conducted by a single expert reviewer; however, a panel of experts may be utilized when a majority consensus is required on highly controversial therapies or procedures.
Quality of care or peer reviews are requested to evaluate the performance of an individual practitioner or institution’s clinical practice. They can address issues or patterns of care related to patient safety, medical errors, and unintended outcomes. All reviews are performed by an expert in the same or similar specialty as the treating provider.
Upon receipt of cases requested for coding/DRG validation HQSI shall perform ICD-9-CM/ICD-10-CM/ICD-10 PCS coding validation and DRG grouping using the Grouper Version(s) defined by CLIENT and/or PAYER and will render a decision based upon applicable recognized coding guidelines and the clinical documentation contained in the record provided to HQSI by CLIENT. All coding and DRG validation shall be performed by RHIA, RHIT and or CCS credentialed staff.