Hitesh Shrawgi
Overview
The client, a mid-sized academic health system based in California, sought a partner to calculate expected reimbursements for all third-party payers based on their respective terms and conditions. PCH Health implemented retrospective underpayment identification and recovery services, providing extensive standard and customized reporting packages.
Challenges
- Calculating expected reimbursement for all third-party payers
- Independently identifying and recovering additional reimbursements rightfully & contractually due
- Modeling all third-party contractual agreements
- Predicting & responding to expected reimbursement for new & renegotiable agreements
- Collecting identified underpayments
PCH Health’s Solution
- Flagged payment discrepancies and enabled detailed data analytics, trend identification, and modeling.
- Combined technology with a professional staff of certified public accountants, registered nurses, financials analysts, and certified coders to deliver positive financial results.
- Provide predictive contract modeling and benchmarking solutions.
- Analyze patient data for all new and renegotiable third-party payer agreements.
- Loaded and maintained all third-party agreements.
- Operated as a contingent, success-based, no-risk endeavor resulting in significant bottom-line impact for customers.
- Eliminated or alleviated systemic payment discrepancies.
- Provided reports that included 837 and 835 data elements.
Results & Benefits
- $12M average annual underpayments identified & recovered
- Achieved 99.6% expected reimbursement accuracy
- 98.4% recovery rate for identified underpayments