FIRM RCM helps level the playing field with our payers by helping resolve complex clinical and technical denials.

Attorney and Clinician Driven Denied Claim Resolution Service

Using both InterQual and MCG Health guidelines, our blended teams of attorneys and clinicians help hospitals and health systems to keep more of what they bill by overturning complex clinical and technical denials. The reality today is that most denials represent a combination of both clinical and technical reasons and require expert knowledge of both disciplines to write effective appeals.

FIRM RCM utilizes contract, case, and statutory principals to protect our client’s rights and reimbursement. FIRM RCM’s attorneys, clinicians, and insurance specialists turn unpaid, underpaid, and denied claims into timely payments. We also vigorously defend takebacks on previously paid claims due to retrospective audits for all payers. The following are examples of claims FIRM RCM has resolved:

Client

Avg Age
(Days)

Avg
Balance

Avg
Resolution Days

A

278

$28,835

42

B

236

$8,959

59

C

169

$87,198

33

  • Claim submitted multiple times without payment
  • Broken promises for payment processing
  • Payments mailed to incorrect address
  • Payments made to incorrect provider
  • Multiple requests for medical records with no payment
  • Short paid claims
  • Incorrect interpretation of contractual obligations
  • Managed care plan issues
  • Silent PPO issues
  • Insurer refuses to honor benefits quoted during verification of benefits
  • Not medically necessary
  • Experimental procedure
  • Patient refuses to supply claim forms and or prior treatment information
  • Pre-certification penalties
  • Charges not reasonable or customary
  • Maximum benefits reached
  • Re-billing for late charges and or missed implants
  • Length of stay issues, days denied
  • Level of care issues
  • High Cost Drugs
  • COBRA
  • Coordination of Benefits
  • ERISA
  • Medicare
  • Medicaid
  • Behavioral Health Denials