TRACE Saves City of Hope $1.1 Million
Provider: City of Hope Cancer Center
Dollar Value: $1,165,144.16
Communication Event: VoiCert
Challenge: Denied for Lack of Medical Necessity
Benefit: Recovery of $1,165,144.16
A patient was admitted to City of Hope in March 2006 and diagnosed
with an acute terminal illness. The hospital used TRACE to record a
notification of admission to the patient’s insurance company. A
concurrent review was provided in April, and the payer responded that all
days were approved. In June, the patient passed away. The next month,
the billing office received a denial from the patient’s insurance company.
The payer’s case manager stated that City of Hope did not provide
sufficient clinical detail, denying the claim for lack of medical necessity.
Along with evidence of 36 clinical reviews provided over a 92-day period,
City of Hope sent transcripts of the calls to the insurance
company. The payer overturned the denial with approval for the entire
length of stay, in part due to the evidence captured by telephone using
TRACE. The hospital recovered $1,165,144.16 in charges as a result. “We
know that sharing the TRACE transcripts of conversations between City of
Hope and the payer played a significant role in helping us overturn this
denial,” stated case management director Anne Tanner.