Utilization Management

How Our Utilization Management Services Work

NYX Health offers a full range of utilization management consulting services to optimize denials and appeal success rates for its hospitals. Its services include prior authorizations, review, and appeal of denials based on retrospective written appeals for commercial, managed care, Medicare and Medicaid denials, secondary claims management, and representation at Administrative Law Judge Hearings. In addition, NYX employs up-to-date medical literature as well as coding clinical validation guidelines to assist in reversing denials and improving revenue recovery. NYX is staffed to become a leading utilization management consulting firm for Healthcare facilities by providing quality services at competitive prices.

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Specializations of 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:

  • Prior Authorizations (e.g., Surgical, Pharmacy)
  • Appeals process
  • Inpatient, observation, and outpatient procedures
  • Behavioral health
  • NICU
  • Inpatient rehabilitation
  • Long-term acute care
  • Coding and Clinical Validation reviews
  • Denial Management
  • Administrative Law Judge Hearings (Federal)
  • Medicare and Medicaid compliance
  • Milliman / InterQual Care guidelines

Data Analysis Capabilities

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, documentation issues.

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.
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