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Mid-sized academic health system identified and recovered $12M

100K

Registered Users

193M+

Lives Supported

864B+

Billed Claim Value Processed (Annually)

5/5

Top US healthcare payers

4K+

Registered RCM Companies

400+

Plans Served

15.7 M

Charts Coded (Annually)

$4B+

Under Payment Identified

50K+

Medical Lockboxes

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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