Third Party Reimbursement Services
For many of our clients, one of the primary focuses of their accounts receivable strategy is to address aging. RPM will exert a concentrated effort on aged accounts which when coupled with the ability to reallocate hospital staff efforts on newer accounts creates an effective combination towards increasing cash flow and reducing aging.
Due to limited staff and high volumes of accounts at our clients, some of them have determined that they do not have the available staff to appropriately follow-up with third party payors. Whether it is to address a specific backlog situation or an ongoing extension of the business office function, accounts are referred to RPM to work the account to resolution, for a defined period or a specific set of events.
The collection effort consists of the use of system-generated letters, claim form review, claim re-billing and telephone contacts. We have the ability to batch claims by payor to maximize the impact on our collection effort. Utilizing the information that we receive from the hospital, we are able to pick up where the provider left off. To maximize recovery we will, if possible, first use electronic billing technologies for initial submission and rebilling of claims. These techniques allow us to increase liquidations and manage a very high volume of accounts. RPM offers a variety of third party recovery programs designed to meet the varying needs of our clients.
A brief description of RPM's various third party program are as follows:
Third Party Denial & Claims Facilitation Programs
Due to the changes in third party reimbursement over the past decade, it is increasingly difficult for health care providers to recover amounts due from contracted and non-contracted payors. The growth of managed care has increased the rate of payment delays and denials to historical levels. The increased volume of denied and improperly paid claims can easily lead to the exhaustion of the resources of the provider's business office staff which must contest the errors of third party payors. Delayed and denied accounts with insurance potential are, as they continue to age, all too frequently placed with collection agencies that do not have the knowledge or expertise to handle complex reimbursement issues.
The process of converting accounts with insurance potential into ineffective third party recovery efforts or self pay collections results in a loss of revenue, a failure to identify recurring denials from large commercial payors, alienation of the patient population who is requested to personally pay for covered services and leaves the provider with a limited path to reimbursement and the potential for patient complaints. RPM has successfully recovered payments from third parties where the claims have been denied for a variety of reasons including: pre-existing condition, out of plan denials, timely filing, usual and customary, eligibility and coordination of benefits issues, medical necessity and needed additional information to name a few.
Designed to facilitate recovery of all balances due from Self-Insured Companies, Union Welfare plans, ERISA Funds, Commercial Carriers, HMO's, PPO's or Private Health Carriers, our services include pending claim intervention and/or denied claim assistance. Not all third party claims are denied or approved, all too many times payors simply fail to process the claim and deny any knowledge of the claim. Accounts with filed claims falling into this category are referred to RPM's Claim Facilitation program. Many of these claims will be paid once the payor is convinced that the failure to process a claim will not be tolerated or ignored. RPM has the experience and resources to quickly resolve any reimbursement problem.
Managed Care Services
In today's health care environment a significant portion of the patient population receives their benefits from a Managed Care payor. This directly translates into a health care provider's account portfolio comprising of problematic Managed Care accounts. RPM has developed processes to help our clients obtain appropriate reimbursement from Managed Care payors.
Our services include a review of Managed Care contracts to ensure that the contracted terms are fair and properly applied. After gathering all of the necessary contracts and rate sheets, we will provide on-site staff to identify denied and underpaid accounts. Those accounts will be referred to our office where we will pursue the payor for full and correct reimbursement.
Upon the referral of accounts to our office we will create unique portfolios for each of the provider's Managed Care payors. This will enable RPM to devote account representatives who are dedicated to specific client issues and are trained to identify poor payment trends. Ultimately this will contribute to eliminating the underlying problems that are causing non-payment. Many of our clients choose to refer all managed care or commercial claims to our office that have aged beyond a certain point. With all of the necessary contract and rate sheet information we are able to continue where the hospital left off and obtain full reimbursement.
In addition to creating biased contracts and interpreting or enforcing contractual clauses in a manner which is not advantageous to providers, Managed Care payors will also try to assert a number of the denials raised by commercial payors. Providers are equipped to deal with this issue to varying degrees depending on staffing levels and the technical expertise of the available staff. RPM has dealt with every conceivable denial situation and is ready to respond point by point up to and including litigation against the payor. We understand the political realities of dealing with contracted payors and our actions take those realities into consideration. RPM will design a program specifically to meet the provider's needs in dealing with the Managed Care environment of today.
Third Party Carve Out
There are situations where our clients have a contractual relationship with another vendor or vendors to do self pay collections. We commonly find that these vendors' focus and expertise stops there. One thing that is unique about RPM is that our procedures are geared toward attempting to collect from the third party prior to initiating a self pay collection effort. Over the years this has given us a tremendous amount of technical expertise in resolving third party issues. Our abilities run the full gamut from retrieving information necessary to process a claim such as a signature on a claim form or accident information, to overturning very complicated exclusion denials up to and including referral for litigation against insurers.
On a regular basis RPM reviews accounts prior to them going to the bad debt agencies and identifies accounts that have third party potential. Those accounts will be referred to our office to work the third party only and will be returned to the hospital at the point it is determined that the balance is due from the patient.
Virtual Staff
In keeping with our commitment to craft innovative solutions for our clients, we have listened to our clients concerns and created our Virtual Staff programs. Medical providers simply identify specific portions of their accounts receivable that are in need of follow-up efforts which can be anywhere from a handful of accounts to the entire receivable. Additionally, our Virtual Staff can provide support services in non-receivable areas of the provider's business office such as credit balance reconciliation, payment and adjustment posting and auditing current account status as examples.
RPM will dedicate staff to the designated work on the client system via a HIPPA compliant electronic connection. There is no programming expense or labor intensive set up involved. Our staff will begin working the aged and backlogged accounts receivable immediately and the client sees an immediate increase in CASH collections. Performance and account activity is monitored on the client system with their reports. As hospitals try to maintain their edge in the marketplace, it is often at an extraordinarily large labor cost. Virtual Staff provides the solution to staffing concerns by minimizing labor costs and staffing aggravations. Virtual Staff is a flexible and cost effective solution that produces the following concrete results:
- Generates immediate CASH
- Resolves accounts receivable backlogs and reduces aging
- Requires no complicated programming/easy set up
- Resolves non-reconciled credit balances
- Minimizes labor costs and hassles
- Account activity is documented on the provider's system
- Provides benchmarks for comparison to internal client staff efforts and results
- Performance monitored on provider's reports
Third Party Outsourcing
Many of our clients have identified outsourcing as a viable solution to resolving the obstacles they face in managing accounts receivables today. Whether dealing with a specific problematic payor or an entire class of receivables such as an identified financial class, in or outpatient accounts, small balance or aged accounts, the goals of outsourcing are the same:
- Increase cash collections
- Decrease days in A/R
- Reduce bad debt expense
- Enhance customer relations
While some RPM clients have chosen to outsource business utilizing the Virtual Staff program described above, RPM also offers this outsourcing service in a non-virtual staff environment. RPM accepts these accounts for referral and manages their work-up and payment on RPM's IT systems.
RPM possesses experience in handling outsourcing situations. Our resources allow us to handle referrals ranging from small one payor arrangements to taking over the entire business office function on behalf of a provider.
Follow-up Services
We have been successful in resolving delinquent and disputed claims with Government payors. Our experience includes actions against Medicare, various state Medicaid programs, Champus, the Veterans Administration, various State Attorneys General's office, the HMO Guarantee Association and the states' Courts of Claims. Due to our unique client base, we have developed an expertise in pursuing accounts where reimbursement has been guaranteed by a foreign government or covered by an out of country insurance or reimbursement policy.
Utilizing our sophisticated electronic claims processes and experienced third party recovery specialists, RPM can provide both initial claims submission and retroactive claims submission and follow-up on all payors, including Medicare and Medicaid. These services can be utilized for special projects and outsourcing.
Liability Program
Patients who receive health care services as the result of an injury caused by a third party (i.e. auto accident) present an additional yet complex alternative for reimbursement. RPM and its associated attorneys will comprehensively investigate police and court records to perfect a statutorily allowed claim (lien) against all parties involved. If payment is not immediately forthcoming, we will request authorization to pursue patient or health insurance payment. Finally, we will vigorously defend the provider's interest should the injury settlement fail to fully repay the provider.
Worker's Compensation Program
Because of the Worker's Compensation statutes, providers are left with limited options to obtain reimbursement in a disputed worker's compensation claim: wait until the dispute is settled; recover the balance from the patient while the case is pending (where not prohibited by state law); or subrogate the claim with the patient's group health carrier. As most providers have experienced, choosing and successfully executing the correct option is difficult. RPM's combination of collection and technical expertise with access to legal resources will result in the quickest, largest reimbursement possible.
Estate Claims Program
Probate claims are difficult for providers to pursue because of the legal formalities involved. Before even filing a claim work must be done to identify the administrator, or executor, and the assets and financial records of the deceased. These matters are best handled by our affiliated attorneys who can ensure the protection of the medical bills. Our affiliated attorneys at Grabowski Law Center will, at the provider's request, intervene to protect the provider's interest through claim filing, research and, if necessary, litigation so that funds are properly disbursed.
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