Revenue Recovery Contingency Services
The BESLER Consulting team of experts deliver proven practices and processes that result in measurable results for your organization. Our team of consultants will support your Revenue Cycle department with a depth of industry knowledge and expertise to better align your institution with strategic goals and corporate visions. We provide the following services on a contingency basis:
Medicare Post-Acute Transfer Underpayment Recovery
Medicare’s post-acute transfer rule, initially introduced in 1998, was expanded significantly for federal fiscal year (FFY) 2005. The rationale behind the rule is that hospitals should not receive full DRG payments for Medicare patients discharged to designated post-acute care settings since a portion of the care is rendered by a provider other than the acute care facility (e.g., skilled nursing facility, home health care). Medicare has edits in place to identify and recover overpayments, but hospitals are left to their own devices to identify and recover underpayments. BESLER Consulting’s process is exceptionally thorough, completely compliant and minimally intrusive. It examines each and every claim implicated by the post-acute transfer rule to find the 2-3% of transfers that are underpaid by an average of $2,000 per claim.
Medicare Post-Acute Transfer Underpayment Recovery Second Sweep Audit
BESLER’s experience is that a Second Sweep following a primary review finds additional underpayments amounting to more than 30% of what the primary review discovered. The BESLER Consulting process includes filing appeals for a redetermination under Medicare’s rules (§ 405.980, Reopenings of initial determinations, redeterminations, hearings and reviews). Providers have the right to request that a contractor reopen its initial determination or redetermination for good cause for up to four years from last payment date.
Medicare Advantage IME Underpayment Recovery
For cost reports starting after October 1, 1997, Medicare remits additional Indirect Medical Education (“IME”) and Direct Graduate Medical Education (“GME”) payments for Medicare managed care patients under changes adopted as part of the Balanced Budget Act of 1997. In order to qualify for these additional Medicare payments, Medicare managed care cases require separate claims processing. The additional GME payment will be included in the subsequent cost report settlement based on the number of IME cases paid. All Medicare managed care claims are eligible for the IME payments as part of a separate bill to the hospital’s Medicare Administrative Contractor. Medicare’s methodology places the burden upon the provider to identify eligible claims and code the affected claims correctly before reprocessing.
Opportunities exist for hospitals, even those that facilitate implementation of corrective measures, to prevent or minimize the possibility of a recurrence. If nothing else, our comprehensive approach will validate that your existing process is complete and is capturing every opportunity. Are you 100% confident that every dollar is collected? In our experience, even in hospitals with robust systems, we are able to identify an additional 15% of claims. Can you afford not to conduct a review?
Given the issues inherent in identifying Medicare Advantage claims and ensuring that IME payment is received, an audit could produce an additional 4-16% in MA IME payments for the hospital.
Section 1011 Underpayment Recovery
The Medicare Prescription Drug, Improvement and Modernization Act of 2003, Section 1011, provided federal funding for emergency health services furnished to undocumented aliens. Maximizing recoveries of these federal funds is a challenging, complex process, and significant amounts remain unclaimed. BESLER currently is data mining files for many hospitals to identify eligible patients and submit thousands of claims for services provided. Recoveries vary depending on the mix of inpatient and outpatient services, but averages $400 per claim in the aggregate.
Medicare Underpayment Recovery
A quarter century of managed care claim auditing reveals that carrier net underpayments consistently average more than 3% of paid claims. The BESLER approach is comprehensive, and includes re-adjudicating each and every claim, both inpatient and outpatient, based on the specific contract terms in place at the date of service. The combination of expert staff with advanced technology ensures that variances from contract terms – both overpayments and underpayments – are identified.
Return to Provider (RTP) Claims Analysis, Quantification and Recovery
As hospitals increasingly adopt more aggressive Medicare collection goals, one proven-effective way to accelerate reimbursement is to reduce the volume of Return to Provider (RTP) claims. No one safeguards Medicare claims like BESLER Consulting. Our RTP Claims Analysis & Resolution service is designed to minimize denials. Because we’ve walked in your shoes, we understand the value of an independent, third party expert entrusted to analyze and resolve your Medicare RTP claims problem. And because we have senior-level, practical knowledge of all areas of Medicare payment, no partner is better qualified to minimize the number of claims returned for correction. A central focus of our correction action plan is on development of new RTP policies and procedures. This typically includes staff training for correcting RTP, and managing RTP in conjunction with daily receivable tasks. We ensure, of course, that RTP claims are Medicare compliant.