Confronted with limited labor resources and increased clinical denials, a Midwest healthcare organization sought cost-effective, bilingual near-shore support to streamline its denial appeals and recovery processes.
The organization partnered with AGS Health to create a skilled team of clinicians specialized in addressing claims denied for clinical reasons, such as medical necessity, length of stay, level of care, and more.
Challenges
- A steady rise in claims denied for clinical reasons had reached a level that strained the company’s already limited clinical resources.
- Escalating operational costs, wage growth, and a growing need for Spanish language support drove the company to seek a more cost-effective, near-shore staffing solution.
Solution
AGS Health assembled a team of highly skilled clinicians, including licensed medical doctors, with expertise in utilization review, documentation improvement, and clinical denial management. To ensure seamless integration, a collaborative training program was developed with the customer, aligning the team with the organization’s unique processes and diverse IT systems across its facilities. Together, they implemented a robust process to analyze denials, evaluate recovery potential, and validate appeal cases using clinical indicators and CMS guidelines, successfully recouping lost revenue.
As the team expanded, AGS Health introduced a structured learning and development system that prioritized workflows based on complexity. This approach created a talent pipeline where team members gained on-the-job experience, progressing from low-complexity cases to high-complexity tasks, including physician advisory support and clinical documentation integrity.
$12M+
reimbursed annually from denied claims
55%
of the total denied amount recovered
~40x
annual return on investment with near-shore staffing
