Updated: Sep 16, 2019
Let’s face it, mistakes in paying claims can and do occur and regardless of their revenue cycle management programs, numerous hospitals and physician practices are owed dollars after contract changes.
Fortunately, the government is compelled to ensure correctness of its compensation through frequent and regular audits. Unfortunately, there is no such oversight or confidence on the commercial side?
CMS regularly uses Recovery Audit Contractors (RAC) to review all claims paid through Medicare. Because of the federal origination, there is heavy regulation to ensure that payments are accurate. However, the RAC audits only identify issues for hospitals within the Medicare space. What mechanism is used for hospitals or physician practices to review their underpayments for their commercial partners and what is the return on this investment?
Commercial payers routinely use overpayment and credit balance audits to ensure they are not over paying hospitals and physicians. With the number of appeals, CMS determined it was cheaper just to settle a payout rather than arbitrate every case. Will your commercial payer partners be willing to do the same?
What mechanisms do hospitals and physicians use to ensure they are being compensated appropriately? Coder quality control is a major practice, and there are firms like MCAG that focus on ongoing contract payment review auditing. Unless there is consistent maintenance and discipline, underpayments are a constant looming threat. One of the best ways to ensure revenue predictability is to have an active monitoring program that reviews your data on a regular basis. Your data needs to be curated for relevancy with business logic algorithms to look for claims that are essentially underpaid.
In an era of shrinking reimbursements and higher cost of care, time spent reviewing for underpayments is well worth the investment. Underpayments may often go unnoticed or seem too time consuming or costly to pursue; however, MCAG offers Contract Payment Review (CPR) solutions to make the process painless and profitable.
The MCAG team of CPR analysts and account managers can provide detailed actionable data to ensure your payments are correct. Along with proper coding, clinical documentation and patient services rendered, tracking payments from payers gives detailed insight into reimbursement methodologies that can help independent groups, hospitals and health systems improve their bottom line.