EdiPhy Advisors: Investigation, Denial and Appeal Response Work

EdiPhy Advisors physician advisors and RNs conduct on-site analysis of process and documentation to identify both strengths and opportunities for improvement in compliance with health care law, CMS guidance and general best practices in medical necessity of patient status compliance. EdiPhy Advisors provides clients with a full report of findings with recommendations for improvement and training options. This investigative work is designed to reduce the number of claims denied for payment by CMS and/or commercial insurance carriers.

When audits and payment denials happen, EdiPhy Advisors physician advisors respond by supporting client hospitals in identifying the most appropriate course of action. EdiPhy Advisors physician advisors possess the expertise and experience needed to analyze patient records and recommend whether the case should be appealed or rebilled; whether denied by a QIO, Recovery Auditor, MAC, ZPIC, QIC or commercial payer.

If we determine that the auditor’s payment denial is incorrect and therefore our recommendation is to appeal, the appeal is written by an experienced physician advisor and sent back to the hospital for submission or will be submitted directly to the denying entity, whichever is preferred by the client. Through our provision of expert support, clients consider EdiPhy Advisors to be a valuable part of their compliance team. EdiPhy Advisors physician advisors are experienced in and available to address the denial and appeal throughout the entire appeals process.

If we determine the payment was denied correctly (because of medical necessity or lack of supporting documentation), we educate our client to support their continuing improvement and compliance efforts.

EdiPhy Advisors regulatory compliance and client physician regulatory education efforts are led by MD/JDs, thus bridging the legal and clinical chasm.