Problems

  1. Healthcare provider managing hundreds of Hospitals and Clinics across the United States struggled to manage and audit national insurance carriers.
  2. Geographically diverse contracts needed a single, consistent, and trusted source for all contract analysis.
  3. Contract negotiations did not include simulations of proposed rates on historical populations, resulting in annually decreasing allowable rates.

Findings

CaseStudy-Appealable-Graph

  • Discovered significant insurance adjudication mistakes (e.g., national carrier had facilities mapped to wrong rate schedules, resulting in a 20% reduction in total allowable).
  • Identified a large degree of variation in allowable rates by insurance and location relative to normalized benchmarks such as Medicare.
  • Staff used three separate systems to gather charge, claim, and account level data.
  • Identified operational process issues in areas such as case management, billing, and price-setting that resulted in a high number of denials and significantly lower than projected payments (i.e. inlier clauses and revenue code exclusions).

Results

  • Allowable-to-charge ratio increased dramatically for top commercial payers as a result of an automated and comprehensive capture of underpayments ($10M+) and projecting the impact of newly proposed payer contracts.
  • Integrated workflows into a single system for analyzing and reporting contract performance at the charge, claim, and account-level, for professional and facility bills (including denials and underpayments).
  • Created a centralized resource for increased transparency of contract logic, documents, and negotiation processes.
"Our organization has used MD Clarity since 2010. The ability of the tool has allowed us to ensure that all surgical claims are reimbursed at the appropriate contracted rates. The MD Clarity Support team is helpful, knowledgeable and very open to ideas to enhance their current system. We are very satisfied with the usefulness of this tool and are continuing to explore how this tool can assist us in other avenues of our business. "
- Mary Wolf, Business Office Director, Twin Cities Orthopedics

Tools Utilized

Identify incorrect payments

Insurance-level analytics and reporting

Straightforward reimbursement analytics