Your hardest denials are clinical. Your escalation should be physician-led.
Your coders, CDI specialists, and appeal writers handle volume well. But when a medical-necessity denial turns on level-of-care interpretation, complex comorbidity burden, or criteria-pathway logic, the argument requires physician-level reasoning. Clinovian is the clinical escalation desk for the cases your internal team escalates.
One suitable recovery can cover the pilot many times over.
$750 – $1,500
Three complex denials reviewed. Full 12-section Escalation Memo on each. Pattern summary included.
$8,000 – $50,000+
Medical-necessity denials on inpatient admissions, DRG downgrades, post-acute stays, and specialty procedures.
One recovery in three
One successful recovery among three reviewed cases may cover the pilot cost several times over.
The cases that stall on your denial dashboard.
Observation vs. Inpatient Disputes
Retrospective status downgrades where the payer converts an inpatient admission to observation. Requires prospective Two-Midnight Rule argument mapped to admission-time clinical judgment.
DRG Downgrades
Paid-but-downgraded claims that never appear in denial dashboards. Clinical-coding crossover reasoning with severity markers, timestamps, and coding-principle framing.
Post-Acute Denials
SNF, IRF, LTACH, and home health admission and continued-stay denials — particularly from Medicare Advantage plans. Criteria-heavy and clinically fact-sensitive.
Medical-Necessity Denials with Clinical Complexity
Cases where the clinical facts support necessity, but the appeal requires criteria-mapped physician reasoning that exceeds coder-level argument scope.
Peer-to-Peer Preparation
Your treating physicians need criteria-mapped briefings before P2P calls with payer medical directors. Clinovian provides the payer's decision logic, not a clinical summary.
High-Dollar Prior-Auth Denials
Complex prior-authorization denials in specialty areas — oncology, cardiology, orthopedics, neurology — where the clinical argument exceeds standard appeal templates.
Clinovian does not replace your appeal writers, your CDI team, or your case managers. The desk receives the cases your team escalates and returns a fixed-format Medical Necessity Escalation Memo — the clinical argument your appeal writer uses to complete the letter. Your team retains the workflow, the submission, and the relationship with the payer.
For concurrent-review escalations during active stays, the desk operates within 24–48 hours. For retrospective appeals, standard turnaround is 48–72 hours. Complex DRG and level-of-care cases may require 3–5 business days.
Pattern intelligence compounds over time. Every case feeds a denial-trend report — payer behavior patterns, denial rationale clusters, documentation gaps by service line. After the first quarter, the pattern intelligence becomes a strategic asset for your CMO and CFO, not just an operational tool.
Every memo includes a prevention note. A forward-looking insight on what documentation practice, if adopted prospectively, would reduce this denial type recurring. Over six months, if the same note appears across multiple cases — "your ED physicians aren't documenting Two-Midnight expectations at admission" — that's a system-level fix that reduces denial volume permanently.
Quarterly Impact Summary for your CFO. Monthly desk clients receive a one-page report: cases screened, cases escalated, "do not pursue" savings, estimated recoverable revenue at stake, denial patterns identified, prevention notes issued. The desk builds its own renewal case — you don't have to.
Clinovian Desk
Fixed per-case deliverable. 12-section memo, 48–72 hour turnaround, recurring pattern intelligence. No FTE cost, no benefits, no recruitment. Scale up or down monthly.
Best for: hospitals with 5–30+ clinical escalations per month who need physician-grade reasoning without a full-time physician advisor hire.
Full-Time Physician Advisor
$250K–$400K+ annually in salary and benefits. Covers broader scope (UM committee, CDI education, real-time concurrent review). But recruitment takes 3–6 months, and a single advisor has capacity limits.
Best for: large health systems with high-volume concurrent review needs and budget for a dedicated clinical leadership role.
These are not mutually exclusive. Hospitals with physician advisors use Clinovian for overflow, specialty cases outside the advisor's clinical scope, and independent second-opinion analysis on high-dollar disputes.
Send one denial rationale. Free suitability verdict in 24–48 hours.
No PHI. No cost for the suitability screen. If the case belongs on the desk, proceed to a 3-case pilot ($750–$1,500). You never pay for cases we tell you not to pursue.