Billing Auditors - Our Services

Below you will find a list of common errors related to contractual items that may result in underpayments from payers. Identifying these errors can help you dispute the discrepancies and recover the revenue you are owed. It is important to pay attention to trends or patterns in order to maximize your chances of recovering meaningful amounts of money.

Our Services

We specialize in underpayments only. This is our bread and butter and because of our success in developing proprietary software built specifically for your organization (we are talking upwards of 6 million lines of code) all your teams hard work will finally be remunerated.  We do all of the following on our dollar.  Everything is contingent on our expertise.  We aren't here to replace your 3rd party billing vendors or sell you some software.  Use us as a stoploss or quality control measure. All these people have already worked their revenue cycles and protocols were followed to be sure.

 

  1. Execute Claims Review Agreement.
  2. Upload All Fee Agreements, Contracts and Addendums.
  3. Data dump of at least the last 2 plus years of 835 and 837 records outgoing claims and incoming EOBs (more years is better - easier spotting patterns).
  4. We analyze each and every contract. Once specifically disseminated we calculate the contracted terms and customized software is generated for each payer. We will target the top 3 insurance payers and those contracts since 90% of their revenue is paid via these 3 payers.
  5. We will run the data dump through the software multiple times in beta modes until our outputs align with the billing teams requirements.
  6. Contact payers and enumerate specific claims that were underpaid.  We will do this over a specific time period to create precedence. 
  7. Once precedence has been established, we will file necessary appeals and reconsiderations - recouped underpayments are remitted directly to the medical organization.

 

JUST A FEW UNDERPAYMENT EXAMPLES 

  1. 120 bed facility located in the southwest had over $5 million in underpayments from just one payer alone.
  2. Medium sized physician group serving a 350 plus bed provider had over $7 million in underpayments.
  3. 50 bed hospital had over $9 Million in underpayments across all payers.

 

Billing Review Quality

Various payer errors lead to underpayments, with contractual items being a common source. One example is the inclusion of "annual escalators" in contracts that allow for payment rate increases. If payers base the payment on the previous year's rate, providers may be underpaid. Another issue is when payers incorrectly bundle services, resulting in reduced reimbursement rates. 

Software Design

One common contractual error is the inclusion of annual escalators in payer contracts. These escalators allow for an annual increase in payment rates. However, payers sometimes make mistakes when applying these escalators. For instance, a contract might specify a 3% annual increase in provider rates. If the payer bases the payment on the previous year's rate, the provider will be underpaid.

Proprietary Audit Development

Another frequent issue leading to underpayments is the incorrect bundling of services. Not all surgical procedures should be bundled with follow-up care. When a payer mistakenly combines these services into one payment, the provider may be reimbursed at a reduced rate, resulting in an underpayment.
 

HIPAA Security

We never access your internal system.  A data dump is sufficient.  "Time is of the essence".

"Payers often establish carve-outs, which allocate specific services or procedures to other plans or insurers. Underpayments can occur when payer representatives become confused about which services, treatments, and medications are covered by their own plan and which are covered by another insurer. For example, certain health plans may cover a wide range of medical services but choose to carve out behavioral or mental health services for coverage by another payer.

Monitor Payer Contracts

It is crucial to stay vigilant and closely monitor payer contracts to ensure that all services are being accurately and fairly reimbursed. By identifying these errors and disputing them, you can recover the revenue that is rightfully yours. Remember to focus on common trends or patterns to maximize your chances of successful revenue recovery.

Reviewing errors difficult with lack of manpower

Overall, being proactive and thorough in reviewing payer contracts is instrumental in identifying and rectifying underpayment errors, ultimately leading to improved financial outcomes for your organization.

Underpayment Epidemic

Underpayments can occur in medical billing when payers mistakenly combine accounts, resulting in the underpayment of fees that the provider is entitled to. This can happen when a patient undergoes multiple procedures on different days, but the payer combines them into one account and only pays for one procedure instead of both. Another issue that can arise is the delay in payments, where payers are often required to pay interest if they fail to make timely payments. Contracts typically specify the timeframe for interest to begin accruing, such as after 30 days of late payment. In such cases, the interest amount should accompany the delayed payment.

Amended Contracts Unilaterally

The contract your organization has accepted includes specific items that may result in a "payment variance" notification. It is important to refer to the contract in order to understand and address these triggers. In case the lost revenue is substantial, it is advisable to advocate for a change in these terms during the next contract update. By doing so, you can potentially prevent or minimize future financial concerns. It is crucial to review and understand the contract thoroughly to ensure effective management of any potential payment variations.

Lessor Of Language

Contracts frequently contain lesser of language that stipulates the payer will reimburse the smaller amount between the charged fee and the contracted rate. These clauses have a substantial impact on the expected reimbursement. To ensure you receive the full revenue you deserve, it is advisable to carefully review and potentially renegotiate these "lesser of" provisions. By doing so, you can effectively maximize your earnings moving forward.

Allowing For Reduction on "CERTAIN PROCEDURES"

Some contracts offer the option to reduce charges for specific services, which directly affects your reimbursement. If a contract allows for a 10% reduction on a certain procedure, failing to apply it correctly could result in a loss of that 10% or possibly even more. Another important provision to consider is the stop loss clause, which establishes the maximum amount the insurer will pay. Failing to account for this provision during pre-billing can lead to significant underpayments. For instance, if a patient's treatment costs $2,000,000 but the stop loss clause limits it to $1,500,000, you would be responsible for covering the remaining $500,000.

What Our Clients are Saying

"I wish I had done this 3 years ago"

Contract Definitions
Underpayments can occur when there are disagreements or misunderstandings regarding the definition of an implant based on policy terms. Healthcare providers may classify a certain medical device as an implant and charge accordingly. However, if the payer's policy defines the item differently and does not cover it as an implant, they may refuse to pay the full amount. For instance, UHC does not categorize liquid or absorbable materials like hemostats and sealants, synthetic sealants, topical absorbable hemostats and topical thrombins, bone morphogenetic protein, bone putty or cement, catheters, staples, and clips as implants. These items need to be billed under a different designation.
Insufficient Documentation
Underpayments may result from various issues within your revenue cycle. Here, we highlight several areas that can lead to such occurrences, along with corresponding examples: 1. Inaccurate coding: Mistakes in assigning correct codes can result in underpayments. For instance, if a healthcare provider miscodes a procedure, it may lead to a decrease in reimbursement. 2. Insufficient documentation: Poor documentation practices may fail to support the services provided, causing underpayment. For example, if a hospital fails to accurately record a patient's condition, it can result in decreased reimbursement for necessary treatments. 3. Inadequate billing processes: Inefficient billing practices can also contribute to underpayments. For instance, if billing staff fail to submit claims in a timely manner, it may lead to reduced reimbursement. Identifying and rectifying these revenue cycle-related causes can help minimize underpayments, ensuring accurate reimbursement for services rendered.
IME Adjustments
IME adjustments are extra payments given to teaching hospitals to cover the higher costs of patient care associated with medical education. Failing to calculate or apply these adjustments accurately during billing can result in underpayments. If a hospital does not include the IME adjustment in their invoice, they may receive less payment for services provided to Medicare patients. Additionally, if a hospital miscalculates or misreports the ratio of residents to beds, they may receive a smaller IME adjustment than they are entitled to. This can happen when some residents are excluded from the calculation or when temporary bed increases are not considered, leading to an understated resident-to-bed ratio and ultimately causing an underpayment.
Errors In Invoicing
Errors in invoicing can result in underpayments, causing potential financial losses. These mistakes can range from omitting certain services or utilizing incorrect billing codes, leading to incorrect payment processing by the payer. Inadequately specifying payment due dates, sending invoices to the wrong recipient, inaccurate service itemization, and misapplying tax rates are frequent errors that contribute to underpayment issues. To mitigate such discrepancies, it is crucial to be meticulous and attentive throughout the invoicing process. By ensuring accurate and detailed invoices, businesses can minimize the likelihood of experiencing financial setbacks due to underpayments.
NDC errors
National Drug Codes (NDCs) are distinctive codes assigned to each drug available in the United States. Mistakes made when including or inputting these codes during billing procedures can result in inadequate payments. If a healthcare provider lists an inaccurate NDC for a particular medication on their invoice, the payer may decline the charge or pay less than expected. Common NDC errors involve utilizing an unverified code, neglecting to follow the 5-4-2 grouping format, and including dashes or special characters in the NDC field. These errors can have negative financial consequences for healthcare providers if not addressed properly.
Some ICD-10 Codes Stand Out
Each payer has their own unique requirements for processing claims, and failing to meet these requirements can result in claim denials or underpayments. For example, a payer may require specific radiology films to support a diagnosis, and if these are not included in the claim, it may be partially paid or rejected. Additionally, payers sometimes interpret revenue codes differently, leading to underpayment. Billing a procedure under one code may result in a lower reimbursement rate if the payer interprets the code differently. In the past, the United States lagged behind in code sets, causing challenges in gathering worldwide health data. However, the implementation of ICD-10 in 2013 has made navigating health crises, such as the COVID pandemic, more manageable.