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.
Fixed-fee physician review. No hourly billing.
$1,000 fixed fee
Three standard denial cases reviewed by physician. Full deliverable, criteria mapping, and pattern summary.
$8,000 – $50,000+
For many high-value denials, the amount at stake in one case may exceed the cost of the complete evaluation.
Three cases, no recurring commitment
A one-time introductory evaluation to test clinical fit and deliverable quality before any recurring arrangement.
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 level-of-care cases may require 5–7 business days, and DRG-downgrade challenges 7–10 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. Recurring-capacity clients receive a one-page report based on cases reviewed and outcome information supplied by the client: cases screened, cases escalated, "do not pursue" savings, client-supplied amounts at stake, denial patterns identified, prevention notes issued. The desk builds its own renewal case — you don't have to.
Clinovian Desk
Fixed-scope 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
One current U.S. hospital posting listed $206,606–$413,212 before benefits and overhead. Covers broader scope (UM committee, CDI education, real-time concurrent review) and licensed capability. But recruitment can take 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 de-identified denial rationale. Initial fit response in 24–48 hours.
No PHI and no commitment. The initial screen confirms scope and the records required. Suitable matters may proceed to a paid evaluation or individual physician review.