A large Midwest-based health system was facing increasing financial pressure driven by rising denial volumes, workforce constraints, and limited capacity to address complex clinical denials. While the organization had existing internal resources, it lacked the scalability and specialized expertise to effectively appeal readmission denials at scale. AGS Health partnered with the organization to supplement its internal team, introducing a clinical denials and appeals solution staffed by physicians designed to improve recovery outcomes.
Challenges
- Growing clinical denials backlog with limited internal capacity to address them
- High labor costs and difficulty allocating qualified clinical staff to appeal growing denial volumes
- High labor costs and difficulty allocating qualified clinical staff to appeal growing denial volumes
- Limited ability to prioritize and triage appeal-eligible cases
- Inefficient processes leading to missed appeal windows and lost revenue opportunities
- Inconsistent visibility into denial trends and root causes
Outcomes
- Achieved 70% overturn rate on readmission denials (vs. 40% target)
- Recovered $4.5M within first six months
- ~50% of appeals still pending, indicating additional recovery potential
- Cleared a significant backlog and maintained ongoing appeal volumes for incoming readmission denials
- Custom analytics and dashboard to identify trends, including those of the 30% upheld denials, to drive readmission prevention strategies
