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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.

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