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Workers Compensation Claims
In most States the method of reimbursement for workers compensation claims is left up to interpreting regulations and the intent of the lawmakers. Even if a State has implemented Medicare’s methodology of reimbursement, the system is always changing and there are opportunities to manage those payments. Who is deciding and interpreting the regulations for the payment of your claims? Give us the opportunity to review the claims that you are processing.
Group Insurance Claims
Most claims are now processed with some type of PPO discount being applied to the hospital’s chargemaster prices. On the out of network claims TPA’s or insurance companies attempt to get some type of discount. Some companies are even taking discounts for out of network claims in the expectation that the provider will process the payment and never recognize that an unacceptable discount was taken. Or they attempt to apply a PPO discount for claims that would not normally qualify. This practice has a risk or liability that may come back to the payer in the future demanding the balance of the claim be paid.
Out of Network Claims: We negotiate with the providers and receive a signed binding agreement on the amount of payment and the discount that will be accepted. We process all claims through our repricing program, utilizing all of the benchmarks that are developed for that claim to negotiate an equitable discount for both the payer and the provider.
PPO Discounts: If the claim is included as part of a PPO contract, we feel the payer is required to honor that contract and accept the discount stated in the contract. We also strongly believe that any payer with a PPO contract needs to review the appropriateness of the current discount they are receiving. We have been able to develop a program that shows which hospitals have been the most aggressive in establishing and increasing their chargemaster prices, and which departments in those hospitals have had the highest price increases.
Actual example:
If you had a 20 % PPO discount with this hospital in 1997, our program has calculated that you would need a 70% PPO discount in 2007 to keep up with the hospital’s price increases. The 70% discount has built in a 6% cost increase for the hospital.
Our software program was designed to review the comparable discount on an overall basis, or it analyzes the price increases on a departmental basis. In the past, hospitals have utilized sophisticated software programs to strategically implement chargemaster price increases. Our program has the capability of uncovering what departments the hospitals have concentrated their price increases. Our program and software is available for every hospital in the country. It can be designed to compare price increases for hospitals in a particular area or even for the entire State. The program is a very useful tool before you start the negotiation process with any provider.
Please contact us to discuss or allow us the opportunity to demonstrate of any of the above processes.
Please call us at (512)852-8265 or (800)906-8085.
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