HealthCheck — managed care auditing

Our Results: Health Check has successfully recovered more than

for clients nationwide. This money was recovered on accounts that the facilities had closed as paid in full.

We provide our clients with detailed reports that not only outline our recovery efforts, but also identify trends and issues that may help the facility reduce future underpayments. In these reports we also identify which payors are underpaying your facility, as well as the top reasons for underpayment.

Case Study 1: Mid-sized hospital in rural market

With 425 licensed beds and over 130,000 patient visits and admissions annually, this hospital serves the 1.9 million people of the large surrounding metropolitan area. The hospital houses a cancer center with a fully-accredited, comprehensive oncology unit. The level 2 trauma center is one of only two trauma centers in the city. The facility is now using a technologically advanced “cell saver” blood recovery system and is a member of a nationwide stroke network. The hospital’s Certified Emergency Department is approved for Pediatric emergency care; and the inpatient facilities include a 22-bed NICU unit and 8-bed PICU unit, along with 32 ICU/CCU beds. The facility is a teaching hospital associated with two nationally recognized post-graduate programs.

Health Check was retained by this hospital in Spring 2006, and auditing services were initiated in June 2006. During the initial six months of auditing at this facility, Health Check’s efforts have resulted in more than $322,000 in additional payments to the facility. From the inception of an audit, it typically takes 90 days to receive the first payments generated by Health Check’s efforts. This is due to the time required to appeal claims with the payors. As the project is now beyond the initial phase, we expect collections at this facility to rise dramatically during 2007.

Case Study 2: Mid-sized hospital in smaller market

Serving a smaller metropolitan area since 1941, this facility has nearly 150,000 patient visits and admissions annually. The hospital currently has 379 licensed beds and is known for its family-centered birthing services, and its newborn intensive care nursery. Health Check has served this client since 2004, and since then our efforts have led to the collection of almost $2.4 million in underpayments from managed care payors.

During our three years serving this client, Health Check has audited zero-balance managed care accounts totaling $345M in billed charges. Of these accounts, we identified 4% as being underpaid an average of $7,900. Significant issues include payors’ failure to pay for stop-loss provisions, plans not paying contracted rates, and indemnity plans’ inappropriate access of discounted PPO and HMO contracted rates.

Case Study 3: Small rural hospital

This facility has served a rural west coast community since 1958 and operates 131 licensed beds. Averaging nearly 150,000 patient visits and admissions annually, the facility’s services include acute medical/surgical care, ambulance service, an ambulatory treatment center, cardiac rehabilitation, cardiopulmonary diagnostic testing, diagnostic imaging, emergency care, a ten-bed ICU unit, outpatient surgery center, rehabilitation services, a transitional care unit, as well as a regional Cancer Care Center that serves the needs of the surrounding four county area. The facility is managed by one of the nation’s premier healthcare organizations.

In the first year of auditing at this facility, over $545,000 has been collected by Health Check from various payors on underpaid accounts. The majority of these underpayments were due to failure to pay implants, failure to pay multiple recurring outpatient services and failure to pay for all days of a patient’s inpatient admission. Health Check was able to identify a billing procedure at the facility that was reducing their implant reimbursements significantly, enabling the facility to correct the problem and avoid future underpayments from one of their largest payors. The facility was also able to collect on a significant number of underpaid accounts after Health Check determined the unpaid services were being billed on the incorrect form.

Case Study 4: Large hospital in an urban setting

This stand-alone facility is one of the largest public healthcare facilities in the state and serves the surrounding metropolitan area with 828 licensed beds. Recently ranked as one of the top hospitals in the country, services include a nationally ranked heart & vascular center, bariatric services, a Level III NICU unit, a nationally recognized cancer center, a hyperbaric medicine department, an orthopedic program that is nationally ranked for both hip and knee replacements as well as for general orthopedic care and a neuroscience department that was nationally certified as a Primary Stroke Center.

In the four (4) years Health Check has been auditing managed care accounts at this facility, over $6M in underpayments has been recovered. This amount is even more substantial considering the client’s internal discrepancy unit that audits accounts before they are submitted to Health Check for review. Health Check identified issues with two of the facility’s largest payors that allowed for settlements that added substantial amounts to our client’s bottom line, including one settlement for more than $2.25 million. The identification of the issues also allowed our client to ensure that their contracts with these payors will no longer contain the loopholes that allowed these underpayments to go both unpaid and unnoticed.

Case Study 5: Large academic medical center in major metro area

This stand-alone academic medical center in a major metropolitan area encompasses a 613-bed hospital, a 61-bed health center, and a medical teaching institution. Clinical services include cancer programs, heart and vascular services, pediatrics, a children’s hospital, neurology and neurosurgery, primary care, orthopedics, women’s services and geriatric care.

Health Check began auditing managed care accounts for the facility in 1999, and to date has recovered more than $4.3 million in additional revenue for the hospital. Our client’s dedication to our services is a testament to the profitable outcome from a long-standing relationship with Health Check. Many of the underpayments at this facility came from failure to pay per a contract’s stoploss provision, failure to pay the correct inpatient rate, and failure to pay the DRG case rate. Health Check has identified several major contract issues at this facility, allowing our client to close these loopholes in their most recent contracts, ensuring underpayments such as these will cease.

Case Study 6: Small hospital with limited managed care presence

This stand-alone facility operates in a rural area and serves patients in a five-state surrounding area. Operating 100 licensed beds, the basic acute care facility offers services including emergency service, cardiopulmonary diagnoses and treatment, a skilled nursing unit, and general surgical services. Health Check’s recovery of more than $500,000 at this facility in our five year relationship is a tremendous success when taking the size and location of the facility into consideration, as well as the limited services available. The lack of major managed care plans in the area has resulted in the hospital’s top underpayment reason being a failure of plans to pay 100% of billed charges due to no contract. These payors often take inappropriate discounts through nationwide PPO plans even though the applicable member is in no way assigned to that particular network nor was there any patient steerage.