Academic Health System Avoids Millions in Lost Revenue

Academic Health System Avoids Millions in Lost Revenue

CHALLENGE

A major midwestern academic health system was searching for a business partner who could calculate expected reimbursement for all third-party payers, based on respective terms and conditions. The purpose was to independently identify and recover underpayments – or additional reimbursement rightfully and contractually due from all third-party payers.

In addition, the health system was interested in a partner who could model all third-party payer contractual agreements in an effort to arrive at a more accurate expected reimbursement for all new and renegotiable third-party payer agreements, and a partner that could supply improved payer and provider benchmarking.

SOLUTION

Exela implemented a Retrospective Underpayment Identification and Recovery service, as well as a Proactive Underpayment Elimination service focused on payers with recurring payment discrepancies.

This work is carried out using Exela’s proprietary software platform coupled with our professional staff of certified public accountants, registered nurses, financial analysts, and certified coders.

Exela also provides a Predictive Contract Modeling and Benchmarking solution. This solution involves analyzing the most recent year’s patient data set for all new and renegotiable third party payer agreements. The analysis arrives at an overall positive or negative financial impact assessment by dollar, percentage, total, and service line. Exela then provides consulting and negotiations services upon request to increase reimbursement potential.

A detailed reporting package covering both service offerings is included in this solution to improve visibility and transparency, and provide operational flexibility to health system management.

Services Included

  • Underpayment Identification
  • Underpayment Recovery (Retrospective and Concurrent)
  • Predictive Contract Modeling
  • Benchmarking
  • Consulting & Negotiation
BENEFITS
  • $12M average in annual underpayments identified and recovered
  • 99.6% accurate expected reimbursement
  • 98.4% recovery rate for identified underpayments (retrospectively and concurrently)
  • 2-3% additional reimbursement above original offer
  • Extensive standard and customized reporting package (including 837 and 835 data elements)
  • Success-based fee structure reduces risk
  • Greatly reduced labor demand - Exela loads and maintains all third party payer agreements and completes all identification and recovery work