MANAGED CARE RECOVERY

Transcription

1 Since 1997, hospitals and other healthcare provider organizations across the country have relied upon ARx as a trusted Partner. Our client requirements have included a wide range of business office operations and revenue cycle management services such as: MANAGED CARE RECOVERY via a partnership with MEDICARE UNDERBILLING RECOVERY EXTENDED BUSINESS OFFICE OUTSOURCING CENTRALIZED BUSINESS OFFICES (CBO) FOR SMALL & RURAL HOSPITALS With a seasoned management team possessing extensive hospital business office experience, a professional well trained staff and adaptive technological capabilities, ARx has built an outstanding reputation for its ability to MOVE RAPIDLY, PERFORM PROFESSIONALLY, AND DELIVER RESULTS THAT CONTINUALLY EXCEED CLIENTS EXPECTATIONS!

2 The Managed Care Recovery Service requires no upfront capital or set up costs, and features a contingency fee pricing strategy based entirely upon the successful recovery of underpaid claims. With this service, ARx receives from its hospital client organizations retroactive and ongoing data feeds of all commercial Managed Care zero balance accounts. Upon receipt, ARx processes these accounts through its own proprietary modeling system. Teams of analysts then verify all systemidentified underpayments (against payer contracts, EOB s, etc.), who then forward the validated underpayments to Recovery Specialists for follow up and resolution with the respective Managed Care payers. On an ongoing basis, ARx provides extensive reporting, documentation and other critical feedback to its client providers that benefit them in their future Payer contract negotiations. See Reimbursement Worksheet below for one example of the reporting that is provided: For additional examples, please see the following page

3 Additional Report Examples: Recovery By Reason Code

4

5 PROCESS INCLUDES: STEP 1: CONTRACTS Physical contracts required for all managed care payers Contracts are reviewed and contract matrices created for each facility, payer, contract period, service type A report of recommendations is made on any obvious deficiencies such as potential interpretation issues or timely filing and carve outs issues Contract matrices are loaded into system STEP 2: DATA EXTRACTS AND MODELING Accounts are loaded into ARx s proprietary system and balanced to Client reports Data includes all demographic, charge, and transaction detail the more info the better Accounts are processed through the Modeler (both expected payment and expected contractual are calculated) Accounts are designated as potentially one of the following: Overpaid Underpaid Correctly Paid Unpaid STEP 3: ANALYSIS Accounts are prioritized by the ARx calculated variance (can be on contractual or payment) Accounts are analyzed/audited to validate payment variances and discrepancy reason codes are assigned Any potential silent PPOs are identified Calculation methodologies are noted in comments Utilizing the assigned discrepancy reason codes on validated variances, similar service accounts for the same payer are grouped onto the analyst s work list STEP 4: RECOVERIES Validated underpaid and small balance active AR accounts are forwarded to our recovery unit for resolution Insurance company is called to recover additional payment Technical appeals are filed for non-clinical underpayments as required by payer (w/ required documentation) Clinical appeals are filed for clinical denials (medical necessity, etc) based on a review of medical records Disputed accounts are reanalyzed Balance adjustments are submitted as appropriate STEP 5: EDUCATION AND QUALITY ASSURANCE Company staff receives in-service on Client contract specifics and state managed care laws Weekly team meetings are held to review issues seen and problems found Regular QA review is done for each team member to ensure process guidelines are followed and feedback given ARx staff is trained on Patient Accounting systems for account reviews, re-bills and adjustments submissions ARx staff is trained on Document Imaging systems for pulling supporting information STEP 6: RESULTS Scheduled conference calls are held with client to discuss results and issues Feedback on payer/contract/facility issues is provided Results are summarized and reported by facility, by payer, and by reason code

6 ARx Performance Statistics: ARx Managed Care Recovery Service Results thru December 31, 2010 # Accounts Processed 2,628,360 $ Successfully Recovered $8,022,875 $ Currently In Process of Being Recovered $3,533,860 Total Projected Recovery $11,556,735 Top 5 Reasons for Underpayments: Reasons for Validated Underpayments % of Total Validated Variances 1.) Partial Charges Processed 18% 2.) Outlier/ Stop Loss Discrepancy 16% 3.) Rate % Paid Incorrectly 11% 4.) Carve-out Discrepancy 11% 5.) Paid DRG instead of Per Diem 7% Top 5 Reasons Total 63%