Medical Underpayments Audit & Recapture
We Save You Money, Or You Don't Pay
Key Benefits
Streamline Operations and Reduce Inefficiencies
Boost Productivity through automated processes
Enhance visibility into critical operations
Scale seamlessly with business growth
Employer & Employee Benefits
Fact #1
Medical providers in the USA are losing $125B+ / year due to underpaid & improperly denied insurance claims
Fact #2
The largest medical payers (think Blue Cross / Blue Shield, for example) are shockingly creative in finding ways and means to pay doctor’s offices, urgent care facilities, surgery centers, hospitals, and the like far less than what they are owed.
Fact #3
100% of audits find underpayments and non-compliance
Fact #4
Recapture 10-20% of revenue (6-8% increase of underpaid Medicare
Fact #5
Our Audits cost you nothing out of pocket so our service is zero risk and 100% upside to your cash flow
Fact #6
Our software is uniquely tailored to you and it takes only approximately 14 days to complete analysis before we start appeals process
WE IDENTIFY, RECOVER & MANAGE:
Underpayments
Denials
Overpayment fines
Responses
Appeals & requests
Negotiation of more favorable contracts
Our Audits cover current 1-2yr contract
While everyone else is content to collect what they can and move on – we focus on those payments received, audits them, and returns to the payor to recapture the difference between what was paid and what should have been.
This proprietary technology identifies and recovers underpayments, manages denials, overpayment fines, and responses, automates appeals and requests, and is a contract modeler in negotiating more favorable contracts. This exclusive system also enables medical providers to recover past underpayments going back to the last 12 months of zero balance claims (those recognized as paid).
The proprietary software and team of experts review every item within a claim encompassing payor contracts, addendums, fee schedules, CPT updates, and clearing houses, providing a forensic third-party audit analysis that maximizes claims recovery and support data for fiduciary reports. Our audit requires minimal time for clients with no up-front cost.
Examples:
Texas – For a 123-bed hospital, we identified $6 million in underpayments through BCBS alone.
Ohio – For a large physician group serving a 500+ bed provider, we identified $7 million in underpayments in BCBS professional only.
Louisiana – For a 142-bed hospital, we identified over $10 million in underpayments for the top 4 payors.
Hospital Network – For a network with 3 of their top facilities, we identified over $30 million in underpayments.
Tennessee – For a small clinic provider who recently started the program, we are uncovering $100,000 to $150,000 more in monthly revenues per insurance contract.
Forensic Analysis
1. Loading Payment Rates and Terms: Contract specialists load the payment rates and terms of the healthcare provider's existing Payer Agreements into the Contract Module.
2. Uploading Claims Data: We work with the healthcare provider's Billing Department and claim Clearinghouse to upload ANSI ASC X12 837/835 electronic files using our HIPAA-compliant, proprietary encryption platform. (The 837 and 835 files are industry-standard files for submitting healthcare claims and payment information electronically.)
3. Identifying Payment Variances: Using these two sources of critical data, our team of experts and software logic identify variances in payment reimbursement compared to the healthcare provider’s contractual agreement with the Payer. The resulting data is organized in an easy-to-use, understandable format.
4. Revenue Recovery Strategy: As the healthcare provider’s partner, we will work closely with their staff to strategize and devise a plan to recover revenue lost due to underpaid, suspended, and incorrectly denied claims.
Contracting
1. Contract Modeler Tool: Our Contract Modeler allows for easy integration of proposed reimbursement scenarios, rates, and contract terms using historical claim utilization data. This tool helps determine revenue outcomes based on a provider’s specific case/service mix and enables the healthcare provider to assess the impact of the Payer’s contract proposal and identify opportunities to maximize revenue.
2. Specialist Team: Our team of specialists consists of experienced professionals with backgrounds in administration, operations, and contracting with major Payers.
3. Consulting and Negotiation Services: We offer consulting services as well as contract negotiation services to support healthcare providers in optimizing their contracts and maximizing revenue.
Analysis & Reporting
1. Data Security and Storage: All data elements captured in the electronic 837/835 files, defined by CMS, are stored in a secure, client-specific environment on your HIPAA-compliant, encrypted server.
2. Reporting Capabilities: Access Plus provides a suite of standard claim utilization reports and the capability to generate customizable, user-friendly reports.
3. Operational Evaluation: This comprehensive data capture offers a detailed picture of the healthcare provider’s service experience, aiding in the evaluation of current and future operations.
We deliver cutting-edge cost-saving solutions and expense reductions to businesses across the USA
We get paid only a percentage of what we recover.
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