Owning money to insurer seems as sure as death and taxes. Even with regulations regarding withholdings and down adjustments, this unpredictable hit to the revenue and cash flow creates pandemonium for CFO and finance departments nationwide. The conversion to ICD-10 last October only added to the complexity. Revenue cycle management systems and programs do their best to ensure there is no revenue leakage. Coding quality management ensures claims are coded and processed. However, mistakes in coordination of benefits to contract changes create constant headaches. Coders and finance cannot keep up with the changes and technology errors. An army of diligent, human eyes would be required to comb through every claim vigilantly. That’s unsustainable, yet avoidable with a good dependent eligibility verification audit.
Underpayment reviews may not amount more than the total overpayments owed, but it can reduce the bill. Every dollar counts as healthcare dollars are being heavily scrutinized by the payer. Why should providers not do the same? Revenue leakage needs to be plugged at every level, and there are numerous underpayments that can be identified. CMS regularly audits to ensure payment integrity for themselves and the provider, but commercial payers do not have the same onus. A major risk is an overpayment bill then tied to a future withholding that will ruin your operation’s cash flow. With proper identification of liabilities, your organization can work with the recovery firm to structure those owed payments favorably and identify the cause of them.
Further, as physician practices and hospitals are bought, liability of outstanding due overpayments often may not be realized until after the transaction. This is huge financial liability that can easily be identified and may significantly change the valuation of the deal. Information is power, ignorance is not an excuse.