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Maximize Reimbursement: 4 Strategies for Success

In today's healthcare environment of increasing costs and shrinking reimbursement, it is imperative that facilities develop strategies that maximize their reimbursement if they are going to survive. Some sample strategies that Regent centers have implemented include negotiating successful contracts with payors, processing claims electronically, performing a complete insurance verification on every scheduled patient, and partnering with a third-party out-of-network collections expert.

Successfully negotiating a favorable contract with payors superficially seems straightforward, but if a simple word or phrase is overlooked, it could have disastrous financial consequences for years. For example, a contract can have very favorable carve-out reimbursement for an orthopedic procedure but not contain language about the implants. Anticipating potentially favorable reimbursement, a center may encourage their physicians to schedule many of these procedures. By the time the first claims are adjudicated and the center realizes that the implants are not covered, they may have performed a half dozen of these procedures with said payor and be out tens of thousands of dollars.

Processing claims electronically is not a new phenomenon in the healthcare industry. In fact, Medicare won't even accept paper claims anymore, and most commercial payors are set to implement the same standard. Centers should submit as many claims as possible electronically, not just for the efficiency gains but also the financial. Submitting claims electronically helps facilities reduce the number of unpaid claims due to "timely filing" restrictions imposed by payors. It is a common practice among some payors to claim that there is no record of a claim on file, even though the center submitted multiple claims. Electronic claim submission, via a clearinghouse in most cases, leaves an electronic trail notating the time/date the claim was sent, whether the claim was sent successfully, and the time/date the payor received the claim. So when a payor rejects a timely claim for "timely filing", the facility can counter with proof that the claim was indeed sent and received by the payor and should be paid according to contractual terms.

Better performing centers maximize their reimbursement by performing a thorough insurance verification on every scheduled patient. This enables them to determine if a patient has benefits, both in-network and out, and make payment arrangements for patients who don't have coverage. Particular attention must be paid to out-of-network and self-pay patients. Many payors have implemented caps on out-of-network procedures that rarely cover costs. Neglecting to perform complete insurance verification may result in a center performing a procedure for little reimbursement or, in extreme cases, for free.

Regent has recently partnered with CollectRx, who specializes in out-of-network third party negotiations. Collect Rx developed a "Business Intelligence Engine" which analyzes thousands of insurance policies and aggregates data from hundreds of customers in order to maximize reimbursement. We have piloted the program at a few of our centers, and have achieved some great reimbursement success. While the pilot is relatively new and the amount of cases small, we have thus far achieved reimbursement between 80 percent and 92 percent of billed charges. If this positive trend continues, we will look to roll out CollectRx to the remainder of our centers.

By negotiating successful payor contracts, processing claims electronically, performing a thorough insurance verification and partnering with a third-party out-of-network negotiations specialist, centers increase their chances of maximizing their reimbursement from payors who are employing more tactics to decrease it.

Learn more about Regent Surgical Health.


Read more insight and guidance from the leadership team of Regent Surgical Health:

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Maximizing Board Productivity

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4 Current Trends Driving the Value of ASCs

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