Appeals

Clinical Appeals

We are
strong advocates for our hospital clients and the patients themselves.

The team of clinical reviewers at Washington & West consists of doctors, physician’s assistants and nurses who each have many years of direct clinical experience. This experience allows them to effectively review each case and elicit pertinent positive and negative findings to support an overturn of the denial. Additionally, all medical reviewers receive proprietary clinical appeal writing training from Washington & West, which provides advanced advocacy skills.

We are strong advocates for our hospital clients and the patients themselves. We approach every denied claim from the standpoint that the vast majority of admissions are medically necessary, and that the services are provided at the appropriate level of care. However, if the circumstances do not justify the level of care provided, or the documentation in the chart is not sufficient, we provide the necessary feedback for educational and prevention purposes.

In addition to their clinical expertise, the clinical reviewers are knowledgeable regarding commonly used nationally recognized Utilization Management criteria, and are therefore able to specifically challenge insurance denials that are based upon these criteria. Our team also has access to an in-house library of texts, references and a subscription-based software programs that provides the most up-to-date clinical information available. Reviewers also maintain collections of guidelines and criteria from major insurers.

Our goal is to ensure that our clients receive payment for the care that they provide.

Our reviewers are investigators—they search the records for the necessary clinical facts and documentation that, based upon their experience, they believe will offer the greatest possibility for an overturn of the denial and then use their skills in advocacy writing to present the information in an effective manner. If you would like to know more about our services please contact us directly at 1-800-704-5574.