Those Who Just Take What the Payers Offer May be Missing Out – Money Left on the Table

This is an issue close to my own heart, as years ago and still even today it’s difficult for me to hopefully get the point across of how important business intelligence software is to mine and drill down to find where you may have been short changed and how to better manage what you have. Years ago I told many physicians that those who run and use the software (the payers) will take your money and win this game as you are operating like a PC with no anti virus protection, something one could understand.

When you are out there in the field trying to create solutions you see all kinds of things, like the “floating patients” on capitation lists when the EOB would arrive for one simple example. The only way to say on top is to have the queries run against what you have been provided. If you don’t, then again there’s money maybe being left on the table. The payers have created the algorithms, which are complicated that run the payment business. This makes me once more again refer to a post I made over a year ago:

The 2 New Hot Words in Healthcare: Algorithms and Whistleblowers

Those 2 items are generating money, maybe not fundamentally correct in all areas, but it is what it is. Some of these folks have some VC divisions to fund too. Holding back on electronic records is one issue, but at least on the money side, don’t hold back on business intelligence software, even if it is very basic and simple in concept for a small practice. BD

When hospitals and clinics get into disputes with payers regarding underpayment of claims, data can be a very powerful weapon, some financial managers have discovered. Armed with detailed information gathered using contract management systems, some providers are reaping multi-million dollar rewards.

"If you do not have this kind of software to get down to the nitty gritty of a claim getting paid right, payers will run over you all day long," says Brian Marx, director of billing at Radiology Associates of Hollywood (Fla.). "Those who just take what the payers are paying them are missing out."

The 10 hospitals in the Washington-Montana region of Providence Health System reaped an extra $8.3 million in payments last year as a result of its data-backed appeals of underpayments, says Matt Blackmore, manager of contract compliance for the region.

"As long as you let payers get away with short-paying you, they'll continue to do it," says Tim Goodson, managed care director at Plano (Texas) Orthopedic, an 11-physician group practice. "The squeaky wheel gets the grease. If you never send in a grievance and let them know you're watching them, the problems will continue."

Providers load claims payment data from remittance advice into the application as well as the detailed terms of health plan contracts and later updates. Using data mining, the application then offers a comparison of anticipated payments based on the contract vs. actual payment, flagging for providers those claims that appear to have been underpaid.

The business intelligence functions of the software take into account extremely complex payment rules as well as bundled charges to pinpoint anticipated payments for a service provided. "A lot of practices are just happy to get paid," Goodson adds, stressing that even the smallest clinics can appeal underpayments if they have the right data. "It's amazing how much money is left on the table."

Fighting for Every Dime

Related Reading: