Case Studies

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Managed Care Denials decrease by 40%

Throughout our five year relationship we have monthly client conference calls regarding the denials we have reviewed. The corresponding reports analyze findings by facility, and by payer. We engage the insurance carrier in the calls and challenge their claims processing and contract terms. As a result, the health system has seen a year over year reduction in dollars denied of over 40%. Our goals are to continually press for a change in behavior by the insurance carrier, and a systematic reduction of reoccurring denials.

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Over Six Hundred Thousand Dollars Recovered From Medicare

We reviewed the Medicare Advantage claims on outpatient cardiac cases. The analysis showed that the hospital was not getting paid on a majority of claims using a specific implant device. An analysis of all Medicare claims was completed revealing over $600,000 was not reimbursed to the hospital. The claims were missing a specific modifier needed for the implant in question. All of the claims were rebilled and the client recovered the amounts due on the stagnant claims before they became uncollectable.

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Additional $1.8 Million in Revenue for ED Medicaid Services

The level of care varies widely for ED visits. It also determines the amount of payment received. In an 8 month period our clinical team reviewed each medical record and appealed those that deserved a higher fee according to state law or the Medicaid managed care contract. We looked at fifteen thousand medical records, appealed over five thousand cases, and overturned 76%. The result was an additional $1.8 million in revenue for eight facilities. We also reported back on trends of inappropriate use of the ED. Referring frequent ED patients to the payor’s case management services helped greatly reduce the number of visits for non-emergent care in the emergency room.

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Sixteen Million Dollar Price Increase Contested

Our hospital client received a notice from a major insurance carrier that they were out of compliance with their contract. Four years prior the hospital put through price increases. Based on an analysis the carrier performed, they claimed a retroactive adjustment requiring the hospital to return over $16 million. The services of our firm were called upon and a proper analysis was completed on the charge master increases made by the hospital. The insurance carrier agreed with the new analysis and the client did not have to reimburse the insurance carrier the $16 million dollars.

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