Level of Care Task Force
Ventra Health’s targeted, specialized approach to appealing underpayments and denials in emergency medicine.
Fighting Level of Care (LOC) Downcodes and Denials
A High-Impact Revenue Opportunity
Downcoding alone can reduce total revenue for emergency practices by as much as 15%. Our dedicated LOC Task Force preserves revenue by identifying and appealing these complicated cases.
Reimbursement for emergency professional services is based on the complexity and severity of the encounter, which is indicated on the claim by CPT codes corresponding to Levels 99281-99285.
Payers are cutting reimbursement in two ways: by downcoding the claim and paying at the lower level (underpayment), or by denying the claim outright for incorrect level of service. The disconnect between billing and payment often comes down to the final diagnosis—and it’s a clear example of bad payer behavior. A high-risk patient who presents with life-threatening symptoms and receives a full workup may still be deemed lower complexity by the payer if the tests come out normal. This practice circumvents AMA guidelines, which expressly state that payment decisions should be based on the complexity of the encounter and not on the final diagnosis.
The Impact
If LOC underpayments and denials are not addressed, practices will see:
Sustained Financial
Leakage
Higher Appeal
Volumes
Increased Administrative Burden
Growing Provider Dissatisfaction
Ventra’s LOC Solution
The Level of Care Task Force takes a proactive, data-driven approach to appealing LOC underpayments and denials.
Identification
With dozens of denial codes and many reasons for denials that fall outside of coding, LOC downcodes and denials may not be easy to spot. Working alongside Ventra’s Data & Analytics Team, we review past claims and dig into payment discrepancies that could indicate an LOC issue.
Comprehensive Analysis
We leverage our industry expertise and longstanding payer relationships to examine policies that may be leading to LOC underpayments and denials. The insights help us strategically appeal past denials and prevent future ones.
Intelligent Appeal
With strong clinical documentation and payer-compliant appeal workflows, our LOC Task Force recovers a material amount of underpaid reimbursement.
Maria Douglas, CPC, CEDC, CPMA
Vice President, Coding
The Ventra Health Advantage
Data and Expertise Are Our Differentiators
The Level of Care Task Force brings together experts from our data & analytics and denials teams to target ongoing Level of Care revenue threats in emergency medicine.
Advanced Agentic AI
Our appeals process is optimized for both efficiency and successful outcomes with AI solutions on Ventra’s vCision™ revenue intelligence platform. Built and managed by our dedicated AI & Automation Team, vCision is an integral part of service delivery for all Ventra clients.
Payer Contracting & Strategy
The LOC Task Force works hand-in-hand with Ventra’s expert payer contract negotiators. We’re on top of policy changes and market nuances that may lead to Level of Care underpayments and denials
Data-Driven Insights
The LOC Task Force uses Ventra’s payer strategy intelligence and insights from vSight™, our powerful data & analytics platform, to uncover payment discrepancies that indicate a likely LOC issue
Coding Leadership
Many LOC underpayments and denials stem from ambiguity in the AMA’s 2023 coding guidelines, which payers are exploiting. We can spot bad payer behavior because we’ve mastered the AMA’s compliance requirements. Read our industry-leading educational white paper
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