Memorial Health System Triples Appeal Capacity
- Adi Tantravahi
- Dec 10
- 4 min read
Memorial Health System (MHS) is a multi-hospital network committed to delivering high-quality patient care. Like many health systems, they faced a growing challenge in managing DRG downgrades and defending complex clinical documentation. Their teams were stretched thin, and the rapid rise in denials made it increasingly difficult to protect earned revenue.
Cofactor partnered with Memorial to bring structure, speed, and visibility to their DRG workflows. What began as a solution for operational backlog quickly became a strategic driver across revenue cycle operations and documentation workflows.
The Challenge
1. Lengthy, high-effort appeal creation
Appeals required ~60+ minutes of manual work per case. At that rate, scaling was impossible. Volume was rising, but capacity was fixed.
2. No bandwidth to appeal every downgrade
MHS teams were receiving more DRG downgrades than they had capacity to appeal. With limited staff and rising volume, they were forced to pick and choose which cases to fight. This meant preventable revenue loss and inconsistent outcomes.
3. No ability to track appeals or measure performance
Prior to Cofactor, appeals were handled manually. The team did not have the time or tools to track every case through multi level appeal processes. Key metrics such as overturn rate, turnaround time, and appeal outcomes were effectively unmeasurable.
4. No systematic insight into root causes or clinical patterns
Without structured data, Memorial could not routinely identify which DRGs were most vulnerable or which documentation patterns needed reinforcement. This limited both financial recapture and preventive action.
The experienced Memorial team knew what needed to be done. They simply didn’t have the bandwidth or infrastructure to do it at scale.
The Solution
Cofactor deployed an appeals solution with automated audit, appeal creation, and full-cycle tracking. The goal was not only to reduce workload, but to provide Memorial with the visibility and confidence needed to take control of their DRG performance.
Comprehensive Automated Review
Every case entering the workflow undergoes a complete review of the medical record, coding guidelines, clinical criteria, and payer policies. This ensured every appeal began with a thorough, consistent foundation that previously required extensive manual effort.
Appeal generation in a fraction of the time The platform automates the mechanical tasks like extracting clinical data from lengthy medical records, assembling structured arguments, and organizing citations. This reduces the cognitive burden on staff and enables MHS to handle significantly higher volumes while maintaining human oversight throughout every case.
Complete Visibility & Actionable Intelligence Memorial gained end-to-end tracking of every downgrade, every appeal level, and every outcome through real-time dashboards. The platform doesn't just track individual cases but identifies actionable patterns across high-impact appeals like sepsis and respiratory cases, continuously improving its ability to reveal exactly which documentation gaps were driving denials and which payer behaviors needed strategic attention. For the first time, Memorial could quantify their denial landscape and use that intelligence to guide both immediate appeals and long-term prevention strategies.
The Results
1. Appeal capacity tripled
With workflows fully streamlined, Memorial’s team went from spending 1 hour per case to just 15–20 minutes, a reduction that provided the operational capacity to appeal everything without adding headcount.
The platform eliminated the tedious, labor-intensive work that consumed hours of staff time per appeal. Maintaining rigorous human oversight on every case while redirecting their expertise from administrative assembly to high-value clinical judgment and strategic prioritization.
2. Complete visibility replaced blind spots
Prior to Cofactor, Memorial couldn't track what they weren't appealing. With only selective appeals being filed, baseline metrics simply didn't exist. Now they have complete transparency into their DRG denial landscape and could now quantify:
Volume of downgrades
Appeal success rates
Time to resolution
Resolution rate
Impact on recovered revenue
3. Revenue protection became systematic, not selective
With visibility established, the financial impact became measurable. Memorial now appeals every appropriate denial, achieving a 35% overturn rate that significantly exceeds the 17% industry standard. On historically difficult cases like sepsis downgrades, where previous success rates approached zero, Memorial consistently wins appeals backed by comprehensive clinical evidence.
The transformation extends beyond operational efficiency to measurable financial return. Memorial had a 5:1 ROI, eliminating the painful triage decisions that once defined their workflow. As their director of revenue integrity put it:
“If we didn’t have Cofactor anymore we wouldn’t have the manpower to appeal everything we’re receiving. We would have to pick and choose which appeals that we’re appealing and we would essentially lose that money.” — Sydney Crawford
4. RCA insights Drive Sepsis Committee
Beyond recovering lost revenue, the platform enabled strategic prevention. Memorial's newly formed Sepsis Committee utilizes Cofactor's monthly root cause analysis reports to systematically identify documentation gaps and proactively address avoidable downgrades. Rather than simply reacting to denials after the fact, Memorial now has the intelligence infrastructure to prevent revenue leakage before it occurs.
Today, Cofactor serves as more than a denials management platform for Memorial, It's the intelligence layer connecting revenue protection, operational efficiency, and documentation improvement into a single strategic workflow.
What Memorial Health System Says
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