Medical Underpayments Audit & Recapture
Streamline operations, enhance visibility, and boost productivity with our tailored Business Process Automation solutions.
☑️ Medical providers in the USA are losing $125B+ / year due to underpaid & improperly denied insurance claims
☑️ The largest medical payers (think Blue Cross / Blue Shield, for example) are shockingly creative in finding ways and means to pay doctor’s offices, urgent care facilities, surgery centers, hospitals, and the like far less than what they are owed.
☑️ 100% of audits find underpayments and non-compliance
☑️ Recapture 10-20% of revenue (6-8% increase of underpaid Medicare)
☑️ You’re not being paid what you’re owed
☑️ Minimum annual revenue – $75M
☑️ Audits cost you nothing out of pocket
- We get paid small finder’s fee from recovered savings
- You receive underpayments directly
☑️ Zero risk + 100% upside to your cashflow
☑️ Timing: approx 14 days to complete analysis → start appeals process
We identify, recover, and manage:
Underpayments |
Denials |
Overpayment fines |
Responses |
Appeals & requests |
Negotiation of more favorable contracts |
- Audits cover current 1-2yr contract
- While everyone else is content to collect what they can and move on – we focus on those payments received, audits them, and returns to the payor to recapture the difference between what was paid and what should have been.
- This proprietary technology identifies and recovers underpayments, manages denials, overpayment fines, and responses, automates appeals and requests, and is a contract modeler in negotiating more favorable contracts. This exclusive system also enables medical providers to recover past underpayments going back to the last 12 months of zero balance claims (those recognized as paid).
- The proprietary software and team of experts review every item within a claim encompassing payor contracts, addendums, fee schedules, CPT updates, and clearing houses, providing a forensic third-party audit analysis that maximizes claims recovery and support data for fiduciary reports. Our audit requires minimal time for clients with no up-front cost.
Forensic Analysis
- Contract specialists load the payment rates and terms of the healthcare providers existing Payer Agreements in the Contract Module. We work with the healthcare provider Billing Department and claim Clearinghouse to upload your ANSI ASC X12 837/835 electronically files using our HIPAA- compliant, proprietary encryption platform. (837 and 835 files are the industry standard files to submit healthcare claims and payment information electronically).
- Using these two sources of critical data, our team of experts and software logic identifies variances in the payment reimbursement and the healthcare provider’s contractual agreement with the Payer. The resulting data is organized in an easy-to-use, understandable format.
- As the healthcare provider’s partner, we will work closely with their staff to strategize and devise a plan to recover revenue lost due to underpaid, suspended, and incorrectly denied claims.
Examples:
- Texas – For a 123-bed hospital, we identified $6 million in underpayments through BCBS alone.
- Louisiana, for a 142-bed hospital, we identified over $10 million in underpayments for the top 4 payors.
- A hospital network with 3 of their top facilities, we identified over $30 million in underpayments.
- A large physician group in Ohio serving a 500+ bed provider, we identified 7 million in underpayments in BCBS professional only.
- A small Tennessee clinic provider who recently started the program is uncovering $100- 150,000 more monthly revenues per insurance contract.
"'Reimbursement wars' keeping hospital execs up at night." - Mercer Health CFO
Contracting
- Our Contract Modeler is designed to “plug and play” proposed reimbursement scenarios, rates, and contract terms using historical claim utilization data to determine revenue outcomes based on a provider’s specific case/service mix. This valuable tool allows the healthcare provider to assess the Payer’s contract proposal’s impact and identify opportunities to maximize revenue.
- Our team of specialists is experienced professionals having worked in administration, operations, and contracting with major Payers. Consulting services, as well as contract negotiation services, are available.
Analysis & Reporting
- All data elements captured in the electronic 837/835 files are defined by CMS and housed in a secure client-specific environment on your HIPPA-compliant/encrypted server. Access Plus offers a suite of standard claim utilization reports and the ability to provide customizable, user-friendly reports.
- This comprehensive capture of all data related to a healthcare service experience provides a picture of the healthcare provider’s need to evaluate current and future operations.
Key Benefits
- Streamline operations and reduce inefficiencies.
- Enhance visibility into critical operations.
- Boost productivity through automated processes.
- Scale seamlessly with business growth.
We save you money, or you don't pay.
It’s that simple.
Platinum Savings Group provides tailored solutions that meet your specific needs.