The Cost of Unclaimed Underpayments: Why Hospitals Fail to Recover Funds Owed by Insurers.

There are a few reasons why hospitals may not pursue underpayments by insurers:

- Administrative Burden - The process of appealing denied claims and pursuing underpayments can be very time-consuming and require a lot of administrative work. Small underpayments may not be worth the effort for hospitals.

- Power Imbalance - Insurers tend to have more power in negotiations than individual hospitals. Hospitals may be hesitant to challenge large insurers out of fear of retaliation or being excluded from provider networks.

- Contractual Obligations - Hospital contracts with insurers often have clauses requiring disputes to be handled through specified appeals processes. Hospitals may be limited in what they can pursue outside of those processes.

- Inconsistent Rules - Billing and reimbursement rules are complex and inconsistent across insurers. Hospitals may lack confidence that underpayments are clearly valid or provable. 

- Financial Resources - Legal action to pursue underpayments can be expensive. Some hospitals may lack the financial resources for prolonged legal battles over small claim amounts.

- Maintaining Relationships - Hospitals have an incentive to maintain positive long-term relationships with major insurers in their regions. They may tolerate some underpayments to avoid jeopardizing those relationships through legal action.

In summary, while underpayment by insurers is an issue, hospitals have to weigh the costs, risks and benefits before deciding to pursue action on any specific claims. The system creates some disincentives for hospitals to aggressively go after underpayments.

Now there is a platform that over 1000 hospitals & medical centers have used for underpayment recovery that is a risk-free addition to their Revenue Cycle Management (RCM) efforts. Their forensic audit is performed on remittances AFTER all other RCM efforts have been completed including other internal or external underpayment recovery efforts. They only engage remittance files that clients expect no further revenues from. 

The typical result is 10%-20% of gross payer receipts in recovery with the only stipulation that they have minimum $2M annual in payer revenue with their top 3 payers.

Let's Start a conversation with our owner and you!!

Larry G. Potter

Senior Advisor

Lgpotter33@gmail.com

Here are some common problems that can occur in hospital revenue cycle management.

 They can include the following:

• Inaccurate coding and billing - If medical codes are incorrect or incomplete, it can lead to denied claims and loss of revenue. Having properly trained coders is essential.
• Long collection times - Slow or inefficient collection of patient payments from insurance companies and patients themselves can tie up funds and hurt cash flow. Average collection times should be closely monitored.
• High denial rates - Denials from insurance companies for various reasons like improper coding, incomplete documentation, lack of pre-authorizations, etc. Denials must be quickly addressed and appealed if necessary.
• Patient registration errors - Inaccurate patient information entered at registration can cause claims to be rejected or sent to the wrong payer. Data entry should be validated.
• Poor charge capture - Failure to record all billable items and services provided during patient care leads to lost revenue. Audits help ensure full charging.
• Lack of pricing transparency - Patients may be unclear on what they will end up owing, especially if they are uninsured or policies have high deductibles/copays. Financial counselors can help provide estimates.
• Failure to verify insurance eligibility - Not checking a patient's active coverage status can mean more claims get denied. Eligibility should be confirmed prior to non-emergency services.
• High accounts receivable days - Letting accounts receivable stretch over 60-90 days can negatively impact cash flow. Close monitoring and follow-up on unpaid claims is essential.

The key is having a well-designed audit system that analyzes every remittance received in a 12-to-24-month period to determine contractual compliance of each reimbursement. 

These case studies demostrate the difference it can make to the bottomline.

Setup a call with the president/owner of our company to review your situation.

Larry Potter

Senior Advisor

Lgpotter33@gmail.com

Text: 1-847-872-4047

Hospital 'business as usual' is eroding your bottom line.

Shore it up an average 22%. (see below)

Larry Potter

Senior Advisor

Lgpotter33@gmail.com

Text: 1-847-872-4047

Hospitals' bottom lines swell after help.

Revenue cycle management has traditionally focused on managing claims and payments after care has been provided. But as payer requirements become more complex, margins tighten and this approach is no longer sufficient. 

Organizations that continue to rely on reactive, legacy RCM processes pay a significant price in foregone revenue.

Look what these four have recouped after a direct call to our president/owner!!

No upfront fees and all recovered revenue goes directly into their accounts!

I will set the call for you right away.

Larry Potter

Lgpotter33@gmail.com

2022 was among the most financially challenging years hospitals and health systems have had to face!

That recovery remains challenging, according to a Sept. 27 report from the American Hospital Association.

Recent reports demonstrate how almost every metric of hospital and health system financial health — including verage debt to cash flow, operating margins, days cash on hand and median cash to debt —  declined last year. Because of that, more than 30 hospitals and health systems that received credit rating downgrades so far this year.

Critics often cherry-pick a select few health systems to make sweeping generalizations about the financial conditions of all hospitals and health systems. As we look back on the last three years, it is clear that 2021 was the eye of the hurricane — a brief period of stability bookended by extreme volatility with more to come!!

$3M lifeline for Greenwood Leflore as supervisors reverse course

The Leflore County Board of Supervisors voted not to allow the hospital to draw on $1 million of credit Sept. 13. The board voted unanimously to reverse that decision Sept. 25 and boosted that number to $3 million, the report said.

The funds should be enough to keep the hospital afloat through the rest of 2023, according to the report. By then, Greenwood Leflore also expects a final decision at the federal level on its application to become a critical access hospital, an application so far denied.

Larry G. Potter

Senior Advisor

Lgpotter33@gmail.com

St. Margaret's Health in Illinois

The CEO, Tim Muntz, has blamed the June closure of St. Margaret’s Health Spring Valley (IL) on the Spring Valley City Bank.

Evidently, the bank "swept nearly $7.3 million" in funds despite a "forbearance agreement" that the two parties entered into 6 weeks earlier. The bank's actions left the hospital "no choice" but to close, Mr. Muntz said in a bankruptcy court filing. 

Mr. Muntz said that the bank swept the funds on June 5 causing the facility to announce its closure on June 12 and officially ceased operations on June 16. 

The hospital filed for bankruptcy Sept 1, while nearby, Peoria, IL-based OSF HealthCare has been attempting to purchase and reopen the closed St. Margaret’s Health Peru (IL) facilities.

It's possible this could have been avoided had the hospital engaged the underpayment recovery program offered by ADHC.

If you would like a direct meeting with the president/owner, send me an email. Thanks!!

Larry G. Potter

Senior Advisor

Lgpotter33@gmail.com