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Related Experiment Videos

Calculating five types of typical underpayments.

T Welter1, P Stevenson

  • 1MedTactics, Arlington, Virginia, USA. terriwelter@medtactics.com

Healthcare Financial Management : Journal of the Healthcare Financial Management Association
|October 9, 2001
PubMed
Summary

Healthcare providers lose significant revenue due to underpayments from payers. Implementing a robust revenue cycle management plan is crucial for ensuring accurate and timely payments, recovering owed funds, and preventing future financial losses.

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Area of Science:

  • Healthcare Management
  • Revenue Cycle Management
  • Contractual Compliance

Background:

  • Underpayments from payer agreements result in substantial financial losses for healthcare providers.
  • Nearly all commercial business for providers operates under payer contracts, highlighting the need for diligent payment verification.

Purpose of the Study:

  • To outline a strategic approach for healthcare providers to identify, address, and resolve underpayments from payers.
  • To emphasize the importance of a proactive plan for ensuring accurate and timely reimbursement according to contractual terms.

Main Methods:

  • Focusing on five common categories of underpayments: late payments, disallowed fee schedule changes, bonus/reconciliation errors, claim denials/downcoding, and non-payments.
  • Developing a systematic process for documenting and proving entitlement to owed payments.

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Main Results:

  • Identification of key underpayment types provides a targeted starting point for revenue recovery efforts.
  • Successful resolution hinges on the provider's capacity to substantiate claims for owed payments through thorough documentation.

Conclusions:

  • A comprehensive revenue cycle management plan is essential for mitigating financial losses due to underpayments.
  • Providers must prioritize accurate payment reconciliation and possess strong documentation capabilities to ensure contractual compliance and financial health.