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The average hospital is unable to collect more than 33-40% of billed claims from insurance companies. We can go back years and recover an additional 15%-20% per year on top of the 33-40%.

Our reimbursement and process management system equips healthcare providers with the tools, data, and business intelligence they need to reduce administrative costs and maximize revenue. The platform enables providers to identify and recover underpayments, manage denials, automate appeals and requests for additional information as well as successfully negotiate more favorable payer contracts. We identify what are considered “Zero Balance” patient claims that the facility considers Paid-In-Full.

Services

Recovery Process:

Client Steps:

  1. Upload sample 837/835 electronic remittance files via web portal.
  2. Upload PDF copy of a single payer contract via web portal.

We Will:

  1. Summarize all Under Payments for a single payer.
  2. Breakdown your contract identifying 5 major points of concern.
  3. Utilize our partnerships with hedge funds, including Morgan Stanley, Merrill Lynch, and others willing to bid on the receivables found by our software. In most cases a bid will be made to purchase receivables within 72 hours.

We have a proprietary forensic auditing software program that identifies underpaid and improperly denied insurance claims for medical institutions as they relate to the contractual reimbursement covenants with their insurers.

Typical billing and collection protocol is to bill, check for billing and coding errors, then re-bill again. The average hospital collects only 33-40% of billed.

 

Our programmers and analysts understand the nuances of your contract with your insurer which typically are intended either to deny, delay or minimize your reimbursement. Our team has experience as contract negotiators on the Payor side and know the language, terms and reimbursement methodologies. We understand the algorithms and intentional “contract confusions” that directly affect your reimbursement. This is what makes us unique.

Insurance contracts are confusing and designed to maximize the insurance companies’ profits, not yours.

We do not replace or compete with your in-house or third-party billing efforts. Our analysts work with your existing billing team and protocols to increase your collections based on our ability to understand the legal issues in an insurance contract and use analytics to identify your contract underpayments.

It is unfair to ask those who bill to be experts in reading and understanding contracts.

It takes 30 minutes or less for a billing person to upload their 835-electronic billing to us in a HIPAA approved drop box.

All we need at this point is an email with one insurance contract to read and upload to our system. Both parties sign a BAA giving us the legal right to evaluate the insurance company’s payments to the facility. Once given the proper electronic files we normally have results in 2-3 days.

This is not an evaluation of the current billing people but rather a forensic analysis of your insurance contracts.

Upon completion of the analysis of the one insurance contract, we will provide the hospital with a report showing the discrepancies in underpayments after taking out patient liability and previous insurance payments. We will also provide a study that will evaluate the probability of collection of the underpayments.

We provide services that will further enhance your reimbursements. These options can be explored once we prove our value.

Case Studies

Our software solution has been developed and tested through analysis of several hundred thousand previously-billed claims. The claims were a collection of dead files and non-payments. We found an average of 15%-20% underpayments on paid claims.

We recently analyzed claims for a small rural hospital that collected less than $19,000,000 last year.  The hospital does not have surgical procedures, or a trauma center. They completed 2,400 surgical procedures, including day surgeries. We found a total of $3,400,000 in underpaid claims. They had previously both billed and scrubbed what had been given to us.

Our software is in over 200 surgical centers being used as a compliment or replacement to their EMR systems.

This analysis is simple and only requires a facility to upload one insurance contract and 6-12 months of electronic billing. This service has a small upfront initiation cost but is subtracted from our portion of the profits recovered.

We provide a written agreement that if we do not find enough funds to cover the service we will provide a full refund of any initiation cost. We have never found less than 10%.

Below is a summary of one account with a total figure of $10,829,549.70

Payer Name

Due

ANTHEM BLUE CROSS ACCOUNT PPO$5,715,828.07
ANTHEM BLUE CROSS ACCOUNT HMO$1,989,039.30
BCBS FEP PPO$1,105,209.77
SISC PPO$877,839.77
CalPERS PPO$548,221.29
BLUE CROSS OF CALIFORNIA (CA) PPO$176,304.59
PPO$148,187.78
BLUE CROSS OF CALIFORNIA (CA) EPO$144,354.36
NORTHROP GRUMMAN PPO$100,296.11
UNIVERSITY OF CALIFORNINA PPO$46,376.31
ANTHEM BLUE CROSS ACCOUNT POS$34,483.30
SPACE EXPLORATION TECHNOLOGY PPO$33,288.49