Level of Care Task Force
Ventra Health’s targeted, specialized approach to appealing underpayments and denials in emergency medicine.
Meet with an ExpertLevel of Care Task Force
Ventra Health’s targeted, specialized approach to appealing underpayments and denials in emergency medicine.
Meet with an ExpertA HIGH-IMPACT REVENUE OPPORTUNITY
Fighting Level of Care (LOC) Downcodes and Denials
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.
1. 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.
2. 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.
3. Intelligent Appeal
With strong clinical documentation and payer-compliant appeal workflows, our LOC Task Force recovers a material amount of underpaid reimbursement.
“Dedicating expert resources to this specialized category of denials reflects our deep insight into payer behavior and our commitment to proactively preserving revenue for our clients.”
— Maria Douglas, CPC, CEDC , 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.
Resources
- Sepsis Across Care Settings: Urgent Care, Emergency Medicine, and Hospital Medicine
Sepsis remains one of the most challenging conditions across the continuum of acute care. Its presentation can be subtle, its progression rapid, … Read more - Becker’s Hospital Review: Managing RCM Disruption with a Strong Patient Payments StrategyAs revenue cycle pressures intensify, healthcare organizations are being forced to rethink how they approach patient payments and overall financial … Read more
- Infographic: Patient Responsibility in the Post-ACA Subsidy EraA revenue cycle reality check for 2026 As healthcare policy shifts reshape coverage and costs, patient responsibility is quickly becoming … Read more
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Find Out More About Ventra Health
Meet our team and learn more about our Level of Care Task Force.
