Our experience has shown that most hospitals are receiving well below the reimbursement to which they are entitled, under their various managed care contracts. 

Therefore, our Managed Care Contract Recovery is designed to maximize payments from managed care payors, using a three-phase approach, as follows:   

• We prepare a contract term matrix, and conduct a general review of all accounts for accuracy of payments.  Our general review will also include an analysis of special contract provisions based on DRG.

• We  review all accounts for "carve outs" i.e. implants, biologicals, etc. based on the ICD-9 procedure codes.   Our methodology of identifying accounts that should have carve-outs by ICD-9 procedure code eliminates reliance on UB Revenue Codes, or on the hospital charging for them at all.  Therefore, even if the hospital never charged for the item, we can identify the account, bill the implant and follow up on the payment.   

• We audit all accounts within $5,000 of the contract's catastrophic limits, in order to find additional charges that push account balance over the limit.

Based on our experience, we can expect to successfully push 90% of the cases near the catastrophic limit over the limit, changing the reimbursement from per-diem to percentage of charges.  

We can complete a Managed Care Contract Recovery engagement – from auditing to final billing – within weeks of our receipt of the hospital’s data.