It is estimated that 3-7% of all insurance claims are underpaid. Identification and resubmission of those underpaid claims offer a tremendous opportunity for healthcare organizations to improve their revenue stream.
Underpayments are a silent revenue killer that often goes unnoticed but can represent millions of dollars in unrecognized net revenue. Underpayments occur when payers fail to reimburse the full eligible amount for services provided by healthcare organizations. Unlike claim denials, underpayments do not result in a rejected claim; instead, they lead to the provider not receiving the full reimbursement they are entitled to, significantly affecting financial outcomes.
- People-related challenges, including capacity constraints, limited knowledge and skill sets, issues with understanding front-end denial causes
- Process-related challenges including differences in the interpretation of contract terms, incorrect calculation of allowed amounts for services, inefficient prioritization of underpaid claims, or inadequate processes governing handoffs between revenue cycle operations and managed care
- Technology-related challenges including outdated systems, data integrity issues, and false positives of underpayments
- Payer-related challenges including incorrect pricing, margin protection issues, lack of standardization in rate cards for complex claims across states, payment variance, incorrect DRG application, incorrect bundling of services, failure to load contracts in a timely manner, and nonpayments
- Support contract load and validation
- Identify underpaid claims and analyze common themes or trends, their underlying causes, and follow-up for correction of underpayment
- Perform underpayment root cause analysis and recommend remediation approaches
- Provide both individual resubmission as well as compile large listing of like-accounts in support of bulk-appeal re-processing
- Offer services for both hospital and physician billing
