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
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