OVERVIEW:
Large Midwestern not-for-profit medical complex and one of America's best hospitals by US News and World Report.

OPPORTUNITY/CHALLENGE:
The system's internal reimbursement team found that locating the transfer DRG (TDRG) reimbursement opportunities among their thousands of patient accounts could be quite challenging. These reimbursement opportunities arise when a patient goes to a different post-acute care facility than the physician intended.

This discrepancy between where the patient was referred to, versus where the patient actually went, resulted in a small error within the patient accounting system that led to significant underpayments or overpayments to the hospital. In cases where key patient account information was incomplete or incorrect, these claims became exceedingly difficult to identify. And, while CMS had closely reviewed their accounts for instances where these deviations resulted in overpayments, underpayments weren't identified so they chose HPS to review their patient accounts to make sure that every TDRG opportunity could be billed.

SOLUTION:
HPS used proprietary software to regressively screen 100% of the patient population that was subject to Medicare's Post-Acute Care Transfer Policy and reconciled the patient encounter data with data in the Medicare common working file. HPS's process combined the results of this regressive analysis with a thorough review by specialists trained to verify all non-conforming claims. Once HPS had identified a pool of claims that did not have evidence of post-acute care activity per the common working file, significant additional research was done with the provider's fiscal intermediary and post-acute cares referral centers to make a final determination. Finally a dedicated Quality Control team performed independent checks to isolate any anomalies and ensure the completeness of HPS's review.

The process was designed with checks and balances to ensure secure handling of all patient data, and process integrity. The process identified all non-conforming transfer claims, including those that have a positive net reimbursement impact, those that are incorrect with no net reimbursement impact and those with a negative net reimbursement impact, HPS then helped the internal team locate and fix any discrepancies in their patient billings to help ensure full compliance with Medicare's compliance standards.

Because the review process made extensive use of HPS automation tools, the review was completed very quickly thereby minimizing revenue recovery time.

RESULTS:

• Recovered $2.14MM in TDRG claims a over a five-year period.
• Client broadened the relationship to include Shadow Billing.