Erroneous application of code-based reimbursement methods creates underpayments.
Our services are funded by the CA$H we collect for your facility
Utilizing our modeling software, we analyze the last three years of patient accounts to determine if the payer calculated their reimbursements correctly. Whether an underpayment is due to miscalculation or inappropriate denial, NET REVENUE will identify and recover this reimbursement.
Our professional staff work with you to develop the necessary files in order to capture the billing and medical record data required to calculate reimbursements. Additionally, we capture all payment/adjustment transactions and properly configure the data to correctly determine how the payer has adjudicated the claim.
NET REVENUE then models your contracts and compares the expected reimbursement to the payer’s settlement of the claim. Our system is flexible enough to model complex methodologies including multi-tier stop-loss provisions and timely payment limitations.
We separate underpayments into categories to recover systematic errors as simply as possible. This often means working with the payer’s hospital representative to correct these payer processing errors and accurately compensate the hospital with lump sum adjustments and/or better future payment terms.
Individual cases of underpayment are then worked case by case - contacting the payers and dissecting their process. Where the underpayment is due to denials, we may also need access to the medical records enabling us to evaluate the validity of a payer’s denial. Our Clinical and Coding Department will then review both systematic and unique cases of denial to determine the appropriateness of the payers’ actions and recover additional payments where suitable.
In addition to the recovery of CA$H, our process provides information on payer actions that can be used in future negotiations. We identify payer processing problems that continue to under pay claims, identify contract terms that reduce reimbursement, and identify denial patterns that appear inappropriate. Moreover, we work with Business Office and Medical Records to correct any related deficiencies in your current process.
Once the process is complete, NET REVENUE will provide ongoing support at no additional cost.
- The intricate terms of today’s payer contracts, combined with transaction volumes and limited resources, makes it essential that your facility have sophisticated payment verification software to compare payer claim adjudication to expected reimbursement!
- If your facility has a payment verification module but it is not modeled correctly to identify claim adjudication, revenue will be missed!