We Have a Solution for the Results of Revenue Cycle Problems and Mismanagement

Some of the latest industry headlines center around revenue cycle management. This is a careful balance between sending out claims and appeals to commercial health insurance companies and patients while ensuring that the hospital or clinic has enough money to continue operating. All that it takes is one misstep, and your finances can head in a negative direction. Over time, these non-payments can add up. Going through the state level appeals process is no guarantee that they’ll get paid. Thankfully, we have a good solution for you – Federal ERISA appeals. How does this work? Let’s go through this step by step.

Decoding Problems with Revenue Cycle Management

Appeals are just one of ten potential problems with revenue cycle management. One good solution to them, according to Becker’s ASC, is to “develop and use customized appeal letters which always include supporting documentation. Incorporate wording of questions that require more than a form letter response from payors. Always take denials to the highest level of adjudication.” As we point out below, this highest level of adjudication is Federal ERISA, which is a good way of getting those appeals paid, should you contact an expert in the field.

Another revenue cycle problem stems from billing issues. We have touched on this before, but one new issue is a lack of a dedicated billing department. That same article points out that “delays in claim submission often stem from business office staff having to perform other tasks which do not allow sufficient opportunity to code or bill claims in a timely manner. Coders and billers need sufficient, uninterrupted time to process claims for on-time submission accurately.” On top of this, the time period between the procedure and claim submission is important as well, since “delays in claim submission can often stem from errors occurring during clearinghouse submission. Always obtain a receipt of the transmission. Shortly after claim submission, check with the third-party payor to verify the claim is on file.” Both of these issues can be easily taken care of, simply by having a dedicated billing staff, as well as delineating which of those staff members should be handling nothing but appeals. Despite this, you will still end up with appeals that go through every possible level until they are paid in full (or not paid at all.)

What You Need To Know About the Appeals Process

Hospitals and clinics tend to go through a lengthy appeals process on the state level, especially if they’re dealing with out of network claims. Here’s how the system works in general: The patients have procedures done or meet with doctors.  Some of these are standard checkup appointments, others are outpatient procedures, and still, others necessitate a hospital stay of some kind. The hospital billing employees go through everything that transpired in order to determine the correct billing codes and amounts. If the procedure was out of network, this is even harder to determine. The assigned codes depend solely on the doctors, the procedures, the care involved, and any medications that are prescribed. These coded bills – now called claims – are sent out the commercial insurance companies. The company that they are sent to depends on who that patient’s insurer is. This sounds easy, right?

At their end of things, the commercial insurance company has a process that they go through in order to pay those claims. In some cases, they’ll pay a portion of it or reject it outright. If the claim was out of network, it’s more likely to be completely rejected. The hospital’s billing staff has the ability to appeal these unpaid and rejected claims at the state level. They can do this three times. The problem is that’s a lot of paperwork to have to deal with in a tight time frame, which is exacerbated even more by the fact that the claim is for an out of network procedure.

Going Through State Level Appeals

In the end, if your clinic or hospital gets lucky, some, or at least a portion of those claims will get paid. If you aren’t lucky, those claims will go and forth for the allotted time frame and end up being completely unpaid. The reasons for this can vary and depend on many different things, including billing codes, pre-approvals (which are hard to come by for out of network procedures), and what the commercial insurance company thinks should be covered or paid for.

After those three state-level appeals are exhausted, your hospital could file Federal ERISA appeals on all of those unpaid or underpaid claims. The problem with this is that your billing staff doesn’t know how to do this, nor do they have the time. The process is complex, and most billing departments are busy either with sending out current bills or wading through state-level appeals. In most cases, those unpaid and underpaid out of network claims end up getting written off.

Federal ERISA: Another Step In The Appeal Process

The Federal ERISA appeals process is designed to get your clinic and hospital the money that it’s owed from those commercial insurance companies, even for out of network care. The process works in a very simple way. Rather than letting those claims sit around or having your accountant write them off, organize them into a file and then contact a company that specializes in these types of Federal ERISA appeals. ERISA Recovery is one such company. We know what we’re doing and have the knowledgeable staff on hand to deal with the Federal ERISA appeals process. In the beginning, all that we will need from you is a list of those claims and some other information. From there, our trained employees file the appeals and will get you that money. At some point, we might need some additional information, but that all depends on the claims and the Federal ERISA appeals that pertain to them.

The best part? We guarantee that we’ll recover at least one million dollars in denied claims within 12 months, and we don’t charge anything for this service up front. We don’t get paid unless you do – we work on a contingency basis. This gives you a great option to choose. Instead of having those claims end up on the wrong side of your hospital or clinic’s balance sheet, you’ll find it in your bank account. We know how tricky it can be to recover these out of network claims and things have been made even more complicated by the January 2018 decision.

Are You Ready For A Solution?

Now that you understand the difficulties of billing out of network claims and how useful the Federal ERISA appeals process is, it’s time to make a decision. You can either let those out of the network claims pile up or lead to possible financial ruin, or you can call us. We can get you that money. All that you need to do is call us today at (972) 331-4140. You can also fill out the contact form on our website. It’s time for you to make that choice.