|
Healthcare Cost Recovery - Carrier Takebacks
Is your facility received an increasing number of refund requests
from HMOs and other carriers?
If you have, you are not alone. More and more HMOs rely on
companies that specialize in healthcare cost recovery to increase
their bottom lines.
While all major HMOs routinely conduct internal retroactive
medical review of inpatient claims, an increasing number of
managed healthcare carriers have started contracting out medical
review functions to third parties that promise to recoup millions
of dollars in previously paid claims.
Companies such as Concentra Preferred Systems, Healthcare
Recoveries, Inc., Primax and others actively solicit HMOs with
the promise that their retroactive claim review will result
in substantial recoveries from providers—whether contracted
or non-contracted—who they suspect may have “overbilled” or
grossly exaggerated the charges.
These cost recovery firms provide HMOs with a new source of
revenue that requires no expense and have captured the attention
of an industry that remains as committed as ever to the reduction
of healthcare reimbursements. Often, the cost recovery firm
works on a contingency fee basis and receives compensation
only if successful in recouping funds previously paid to the
provider subject to review.
Most healthcare cost recovery firms employ former HMO auditors,
who are well trained in the job of performing retroactive claim
review. These external reviewers scrutinize itemized claim
forms looking for any line item or group of charges they can
recommend that the HMO reduce or eliminate from payment consideration
to the provider.
Lately, healthcare cost recovery firms have seized upon so-called “cost
to charge” ratios and routinely analyze broad geographic
data in an effort to slash the amount of reimbursement available
to the provider who is deemed to have “marked up or inflated” charges.
The end result usually involves the HMO either submitting a
refund request to the provider or more egregiously, an offset
or reduction in prospective payments due on separate claims.
HMO COST RECOVERY—HOW CAN THE
PROVIDER
CHALLENGE RETRO
REVIEW?
Our experience suggests that any provider confronted with
an HMO or other healthcare carrier seeking recoupment on previously
paid claims consider the following:
Ensure that your facility has a solid basis and understanding
of its charge master and its cost-to-charge ratio—having
trustworthy and verifiable documentation will provide both
a defense when your charges are challenged and an offense should
you need to dispute an over billing allegation.
Make certain that your facility is billing in accordance with
both the rates contained in its charge master as well as pursuant
to any managed healthcare agreements it has in place.
Creating confidence in your billing as well as the method
in which you expect to receive reimbursement will provide a
steady and dependable foundation when disputes arise as to
initial claims adjudication and payment or when faced with
retroactive claims review and prior payment recoupment.
We can help in the event that you encounter difficulty in
challenging and overturning HMO denials and underpayments.
Our law firm concentrates almost exclusively in the representation
of hospitals and medical providers and we can provide quality
legal services on a contingency or hourly fee basis.
|
