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MEDICAL REVENUE OPTIMIZATION
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Payment Shortfalls Recovery System

Our Recovery System consists of a team of payer contract experts and the most advanced forensic audit software system in the healthcare space. Our audit analyzes every remittance received in a 12-to-24-month period to determine contractual compliance of each reimbursement. Our team then works with the payers to recover payment shortfalls that are due our clients.

PROVEN PROCESS

Our team of contract specialists reviews each payer contract in detail and loads the contract payment rates and specific terms into our software system. We also work with the healthcare provider’s billing Department and claim clearinghouse to electronically upload your ANSI ASC X12 837/835 files using our Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant, proprietary encryption platform. 

Our software development team then writes custom algorithms specific to the client’s contract rates and terms to perform the forensic analysis.

Our team of experts and software logic identifies and reviews the variances in the actual reimbursement versus the payer’s contractual obligation.

As the healthcare providers partner, we will work closely with their staff to strategize and devise a plan to proceed with recovering revenue lost due to underpaid, suspended and incorrectly denied claims.

Critical Addition to Your Revenue Cycle Management

Our payment shortfalls recovery service is a risk-free addition to your Revenue Cycle Management (RCM) efforts. Our forensic audit is performed on remittances AFTER all other RCM efforts have been completed including other internal or external payment shortfalls recovery efforts. We only engage remittance files that our clients expect no further revenues. Therefore, our services compliment all other RCM efforts and provides new revenues…100% of the time.

100% Success Rate

Our results are unrivaled. To date we have analyzed billions of dollars in reimbursements and remittances against 1,000s of unique and often complex payer contracts and have found noncompliance and payment shortfalls for 100% of our clients. The typical result is 10%-20% of gross payer receipts in recovery.

Risk Free Engagement

We work solely on a contingency basis. There are no upfront fees, costs, ongoing tasks required from our clients. We take on 100% of the risk and effort to recovery revenues for our clients. We are only compensated when we successfully recover payment shortfalls.

SUPERIOR RESULTS

We have analyzed billions of dollars in reimbursements and remittances against 1,000s of unique and often complex commercial contracts and have found noncompliance and payment shortfalls for 100% of our clients. The typical result is 10%-20% of collections from payers.

Sample Case Studies:

• 123-bed Texas hospital: $6 million in payment shortfalls through BCBS alone. 

• 142-bed Louisiana hospital:  $10 million+ in payment shortfalls for top 4 payors. 

• Large Pennsylvania Private Hospital: $1.2 million in payment shortfalls

from their 4th largest payer. Represents 18% of their collections for the payer. 

• A hospital network: $30 million in payment shortfalls from just three facilities. 

• A large Ohio physician group: $7 million in payment shortfalls in BCBS professional alone.

• A Tennessee clinic: $1 to $1.5 million in payment shortfalls per payer contract 

• Small Texas Community Hospital: $4,048,555.44 in payment shortfalls

from BCBS alone.

• A Missouri hospital: Over $20 million in payment shortfalls

PERFORMANCE BASED EXPERTISE

Forensic analysis to determine contractual compliance and recover payment shortfalls for our clients is our primary corporate expertise. We are the only provider in this space with this sole corporate mission. Given we are undiluted with other pursuits, our results are demonstrably superior to others who offer similar services as an ancillary. Furthermore, we operate on a performance only basis in that we are paid a fraction of what our clients actually receive in payment shortfalls recovery.

What is the cost?

$0 upfront fees. Medical Revenue Optimization funds all the cost and risk including contract load fees, appeals processes, audit and training which is applied to our recovery fee. Our fees are 100% paid by a % of recovered payment shortfalls fees from the initial audit of past claims.

Where do the payment shortfalls go when recovered?

All payment shortfalls are paid directly to you by the payers. Medical Revenue Optimization bills you a % of recovered payment shortfalls after you have been paid.

What do you expect to recover in past payment shortfalls?

The payment shortfalls System historically uncovers 5-30% of commercial payments which have been paid incorrectly on every analysis. Our collection statistics for commercial payer payment shortfalls are 85-90% of identified claims. The majority of contracts allow providers to appeal claims that have been underpaid or paid incorrectly for up to 12 months from the last response by the insurer.

After 12 months, they will expire, at which point you will never be able to bill or collect. Our system recovers additional payment shortfalls owed on zero balance accounts. Dollars underpaid after EMR/EHR and billing systems have fully processed claims as “PAID IN FULL”.

How long does it take to complete your analysis audit process?

Minimum facility time is 30 minutes or less to upload 835-electronic billing records through our proprietary encryption platform, which uses the highest HIPAA standards. Once we have received all contracts and data files it typically will take around 14 days to complete the analysis and start the appeals process.

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