The underpayment challenge: Capturing dollars through an organized approach to payment compliance

Area of Science:

• Healthcare Administration
• Medical Billing and Revenue Cycle Management

Background:

• Effective revenue cycle management is crucial for healthcare financial stability.
• Many practices struggle with payment compliance and underpayment recovery.

Purpose of the Study:

• To outline key strategies for enhancing payment compliance and revenue recovery.
• To provide actionable steps for optimizing healthcare financial operations.

Main Methods:

• Utilize practice management system functionalities for compliance.
• Establish an internal denial management expert role.
• Implement robust cash posting processes.
• Categorize underpayments based on required actions.
• Develop specific policies for dealing with PPO (Preferred Provider Organization) contracts.
• Engage senior leadership in financial process improvement.

Main Results:

• Improved accuracy in payment posting and compliance.
• Reduced claim denials through specialized internal expertise.
• Systematic approach to addressing underpayments.
• Enhanced negotiation power with PPOs.
• Increased overall revenue cycle efficiency.

Conclusions:

• Leveraging existing systems and developing internal expertise are vital for payment compliance.
• Process integrity and strategic policy development drive financial success in healthcare.