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15. Underpayment Recovery

Often times, hospitals with numerous complex HMO contracts accept the payment received from the HMO as payment in full. M.L. Schwartz and associates has evaluated several companies who offer underpayment recovery and has observed several others in client hospitals. One company stands out based upon its track record, ease to work with, integrity, and reasonable contingency pricing. Mr. Schwartz is proud to introduce his clients to this company.

This company has been in business for over twenty years and has served over 350 hospitals and about two dozen very large physician practices (mostly academic medical faculty plans) in 35 states. The company includes among its clients Rush Presbyterian Hospitals, Aurora Health Care, Harvard, The Cleveland Clinic, Community Health Systems, Essent Healthcare and hundreds of other large and small hospitals and hospital systems. The services and products offered include financial consulting related to pricing and net revenue modeling, software products and ASP services related to contract management, budgeting, cost accounting, and decision support in addition to the recovery services referenced above.

This company now has over five years of history related to its recovery efforts. During that time the company has performed this service for nearly 100 hospitals in 20 states. As of June 2008, the average recovery for hospitals was almost $200,000 with recovery of up to $2.0 million for some hospitals.

The process is initiated by the contracting hospital sending billing and payment data related to the patients and contracts subject to review along with copies of the original contracts. The company enters the contracts and the data into its proprietary contract management system and the company then reviews each account at two levels. The first level identifies underpayments related to contract terms, the second level relates to focusing on particular types of accounts that are frequently subject to underpayments because of incomplete billing information or coding. Where potential underpayments are identified, the company confirms them by dialing into your hospital's information system. Following confirmation, payment is sought on behalf of the hospital. All recovery payments are sent directly to the hospital or corporate entity for crediting to the appropriate account.

The data requirements are generally readily exportable from your existing patient accounting system which makes the process as un-intrusive as possible and most of the effort is performed electronically and by telephone. Naturally, the company is in full compliance with HIPAA and other confidentiality agreements.

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