U.S. hospitals write off between 3% and 17% of their annual revenues to claims denied as a result of coding errors, incorrect coding, lack of pre-approvals, lapsed coverage, and timed-out claims. More than 50% of these claims are written off by hospitals without any intervention. Denied claims are forecast to grow by over 400% in the next four years driven by increasing complexities of payer reimbursement methodologies in both public and private insurance systems, adding to already increasing financial pressure on hospitals. Factors include:
- Decreasing reimbursement rates, government involvement.
- An aging population that reduces their ability to shift costs between younger commercially insured patients and older government insured patients, and the impact from the Patient Protection and Affordable Care Act (PPACA), “Obamacare”, that decreases Medicare Advantage, lowering the threshold for Medicaid eligibility, and creating dual eligibility membership in Medicare and Medicaid.
- The U.S. market will be moving from ICD-9 to ICD-10 classification of disease codes in 2015 which will increase the number of billing codes by a factor of 6, significantly increasing the complexities of claims reimbursements.
- Vast inefficiencies of the U.S. medical systems.
Certive is a provider of claims audit and recovery solutions in the revenue cycle management segment of the U.S. healthcare market. Certive engages directly with hospitals and its solutions combine deep domain expertise, industry connectivity and technologies that drive efficiency, scalability and insight into the claims audit and recovery process generating significant revenues in a low-friction revenue sharing business model. Certive’s lines of business are:
- Zero Balance. The auditing of claims to identify underpayments by comparing actual payments to contracted terms for such specific procedures and recovering differences on a revenue sharing basis with the hospital. The process also tests billing performance to ensure that payments are equal to the services performed.
- Billing Support. Analyze claims to be submitted for payment prior to billing.
- Early-Out. Audit and collection of claims before the expiration of the contractual period with the payer on a revenue share basis.
- Clinical Review. The review and audit of any claim items that have been denied for clinical reasons, and the recovery on a revenue share basis of any discrepancy identified.
- Charge Accuracy and Chart Review. Retrospective audit of claims to identify and collect missed reimbursements.
- Special Projects. Niche opportunities for audit and recoveries identified through an understanding of the regulatory environment.
Certive’s business process management solutions increase both the speed and amount of revenue recovery, and enable scaling of existing collection efforts. These solutions are based on a combination of licensed and proprietary platforms that utilize a combination of workflow technologies, analytics, and business intelligence processes. Certive leverages its technology with its domain expertise and industry connectivity automating claims audit management in a revenue sharing business model with the hospital.