Utilization Management

utilization management in healthcare

Maximize Revenue

NYX Health offers a full range of utilization management consulting services to optimize your revenue cycle processes ensuring that healthcare resources and outsourced services, such as prior authorizations and denial management, are utilized appropriately and efficiently. 

  • Cost Control - control costs associated with unnecessary or excessive use of resources.
  • Revenue Maximization - maximize revenue by accurately capturing and billing for medical services provided.

Our Professionals

NYX is a leading utilization management consulting firm in healthcare and offers a full range of compliance and appeals services to hospitals. Our staff consists of experienced US-based physicians, administrative, and IT professionals with experience in the following areas:

denial management
  • Prior Authorizations (e.g., Surgical, Pharmacy)
  • Appeals Process
  • Inpatient, Observation, and Outpatient Procedures
  • Behavioral Health
  • Inpatient Rehabilitation
  • Medicare and Medicaid Compliance
  • Long-Term Acute Care
  • Coding and Clinical Validation Reviews
  • Denial Management
  • Administrative Law Judge Hearings (Federal)
  • Milliman/InterQual Care Guidelines
  • NICU


Evaluation of ED discharge and hospital admission data to identify trends that have the potential to prevent denials, maintain better compliance, and support successful appeals. Evaluation of historical claims data to identify specific denial reasons as related to clinical, coding, administrative, and documentation issues.

data analysis

Potential Trends Include:

  • ED treats and releases patients that may have been more appropriate for observation status.
  • Observation admissions that may have been more appropriate for IP status.
  • Observation and IP status that were changed after admission.
  • Potential condition code 44 cases.
  • Status correlations with diagnosis codes, lengths of stay, admitting attending, etc.
  • Administrative errors (timing of signed order, no signature, illegibility, etc.).
  • Poor documentation by diagnosis and by attending, leading to improper denials.
  • Coding errors and inconsistencies.