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: Certive Health's 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 Health screens accounts using logic rules and analytics skilled clinicians to identify missed charges by comparing the patient bill to the medical record. This ensures capture of all missing charges, DRG errors, and coding errors. Certive Health handles the entire process including recovery of lost charges. The solution is both a revenue integrity service and part of a comprehensive internal compliance program.
Certive Health's lines of business are:
- Revenue Integrity Analytics. Certive Health's Advanced Analytics identifies 10-20% more coding errors even after scrubbing by competitor's solution ensuring every dollar that can be collected is found, and claim accuracy which is becoming a significant need.
- 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.
- Silent PPO. Unauthorized discounts taken by payers outside the scope of the contractual language. In most cases, the patient was not in a PPO plan but rather an indemnity plan. In others, the patient went out of his/her network and received a discount from a second PPO. This is not allowed in most PPO contracts.
- Aberrant DRG assignments. Using special edits and combined with our Revenue Integrity Analytics to ensure accurately assigned DRG's and resubmitting for additional dollars when found.
- Denial Management and Pre Authorizations. Translate denial code from different payers into a common file/screening tool.
- Certive Assurance Compliance. Using components of capabilities in our other lines of business geared to identify over-coding and over-billing that could otherwise lead to scrutiny and/or investigations by HHS/OIG.