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Physician Advisory Services

Hospitals and physician groups operate in an environment inundated with rules and regulations, with multiple federal, state, and commercial entities auditing compliance. These factors drive the need for precise and timely case classification, as well as formalized admissions and billing processes.

The decision to classify a patient as inpatient versus observation is based on complex medical judgment, made all the more complicated in light of The Centers for Medicare and Medicaid Services’ release of the FY 2014 Hospital Inpatient Prospective Payment System (IPPS) Final Rule.

Nirvana Health Group focuses on concurrent recommendations to increase compliance and success on retrospective appeals and maximized total utilization review (UR) compliance through a full suite of IPPS “two midnight” standards and services performed only by licensed physicians.

Nirvana Health Group is a comprehensive physician advisory and medical necessity solution that helps hospitals and medical facilities confirm their navigation of the regulatory environment so that compliance improves.

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Admission Status Review

The assignment of patients to inpatient or outpatient status (with or without observation) is based on complex and ambiguous Medicare regulations. This distinction drives all of hospital billing, yet is fraught with errors. Nirvana Health Group Clinical Solutions employs physicians and trains them on the ins and outs of the regulations so they can assist the treating physicians to correctly categorize patients for billing status utilizing a user-friendly web portal and remote access to the hospitals electronic medical record.

First Level Review

Nirvana Health Group Clinical Solutions employs as Utilization Review Specialists; who are highly proficient in the application of recognized evidence-based criterion to provide remote first level review. We are able to provide a customized program designed to meet a hospital’s utilization review (UR) needs; including obtaining authorizations as well as coverage of UR functions during non-traditional coverage hours on evenings, nights, weekends and holidays.​ Nirvana Health Group’s First Level Review services are a cost effective solution to augment existing staffing resources or to increase UR service delivery outputs.

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Appeals & Denials Management

Nirvana Health Group’s Clinical Solutions has had outstanding success in appealing RAC, MAC, and other Medicare audit denials of hospital billing. Our success rate in overturning denials of billing based on our recommendations is greater than 95%. We offer commercial appeals within the parameters of the hospitals contracts. The first step in the appeal process is to determine whether the physicians documentation is strong enough to support an appeal. We will advise a client if in our judgment a case is not appealable. For any government payer case on which our billing recommendation was followed, we status assure by providing no-cost appeal of any denials at the first two levels with a small charge for appeals to the Administrative Law Judges and above.

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Focused Chart Audits

A predetermined amount of focused chart reviews for compliant billing status regarding inpatient, observation or outpatient status as well as trending for documentation to support medical necessity of the hospitalization: includes a brief explanation of each case with analytic and trending of the group.

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Payer Peer to Peer (PPTP)

A concurrent denials management service in which our experienced physician advisers discuss the commercial denial with the payer during the hospital stay on your behalf. We arrange the phone discussion with the medical director who denied the claim to seek inpatient authorization for the encounter, as appropriate.

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