U.S. hospitals lose between 3% and 17% to missing charges, coding errors, incorrect DRG assignments and denials. 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. Other complexities 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.
- Vast inefficiencies of the U.S. medical systems
The Solution: Revenue Integrity Analytics - Certive Health's Lost Charge Recovery and Compliance Solution
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:
- Managed Care Underpayment. 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.