How to Quantify a Gut Feeling You’re Leaving Reimbursements on the Table:

4 Simple Benchmarking Tasks to Assess Payments and Billing

If you work in the finance or business office of a hospital, you’ve probably experienced a gut feeling that your hospital is not maximizing its Medicare reimbursement. However, it can be difficult to determine whether your gut feeling is accurate or not, and without that quantification, it can be impossible to identify where leakage is occurring or how to fix it.

The biggest hurdle that hospitals face in identifying and quantifying missed reimbursement is limited resources. Hospital finance teams have a wide range of day-to-day responsibilities and many simply don’t have the time or technology needed to analyze the extensive sets of data used for Medicare reimbursement.

Healthcare Payment Specialists CEO Todd Doze explains how to quantify missed
reimbursements and identify actionable process improvements to maximize payments.

4 Benchmarking Tasks for Hospitals to Quantify Missed Reimbursement Opportunities

While a comprehensive Medicare reimbursement analysis can be difficult to perform, there are a few simple benchmarking tasks hospital finance executives can do to assess payments and billing to quantify missed reimbursement or savings opportunities:

1. Examine Crossover Claims

Take a look at Medicaid denials secondary to Medicare. Secondary insurance payments are often overlooked, but significant lost reimbursement may be at stake. When this happens, not only is your hospital losing out on coinsurance and deductible payments, but it may be unable to correct the bill fast enough to get it to Medicaid within timely filing rules. It may also impact Medicare Bad Debt, as Medicare Administrative Contractors (MACs) require hospitals to bill Medicaid correctly before they will allow a Medicare Bad Debt payment.

2. Check SSI percentages

Determine your hospital’s Supplemental Security Income (SSI) percentage relative to the percentage of coinsurance and deductibles that are written off. SSI is a strong indicator for Medicare Bad Debt, as there is significant overlap between the two populations. In general terms, the higher SSI percentage, the higher the expected Medicare Bad Debt.

If your SSI is going up, but your bad debts are going down, and neither the state’s approach to payments secondary to Medicare nor your hospital’s policies have changed, it could be an indicator you are missing some portion of your Medicare Bad Debt population.

3. Make sure every Medicaid-eligible day is accounted for

Whether you rely on external vendors or your own internal processes, make sure you do a true-up of Medicaid-eligible days for the purpose of calculating Medicare Disproportionate Share. True-ups help hospitals capture all retrospective Medicaid membership changes as patients can become retroactively eligible or ineligible for Medicaid after their hospital stays. A true-up helps hospitals ensure that they take advantage of all available retrospective opportunities. The best strategy is to re-investigate your Medicaid-eligible days just prior to any MAC audit of the cost report.

4. Assess your Medicare Advantage patients

Take a look at the number of Medicare Advantage patients you have to make sure all of your Medicare Advantage bills are being sent to Medicare Part A for the shadow billing opportunity.

Over time, Medicare Advantage plans change by region and by county. Staying on top of which plans are offered in your area will allow you to better identify those patients at registration. Finding the complete population of Medicare Advantage patients has wide-ranging implications associated with: Indirect and Graduate Medical Education reimbursement, Medicare Advantage Bad Debt reimbursement, CMS compliance guidance, hospice transfers and other cost report and hospital-specific situations.

The Next Step to Maximize Reimbursement

While the above tasks might validate a gut feeling about whether or not a hospital is doing everything it can to maximize its reimbursement, they won’t solve the problem.

Hospitals should consider having a third party examine their results—regardless of whether the work was done by a vendor or internal processes. There’s a common assumption that every company that handles Medicare Reimbursable Bad Debt or other payment solutions is the same, which leads hospitals to make the decision solely based on the service’s price and fees.

The old saying, “you get what you pay for,” holds true in this case. There are many companies that will offer to take a look at payment issues on an at-risk basis. This can help hospitals validate whether or not they’re receiving all that is entitled to them, as well as if their outside vendor is providing a worthwhile return.

Navigating the landscape of Medicare and Medicaid reimbursements, with constantly changing regulations and policies, can be daunting. But you can take action. Ready to learn more about getting the reimbursements you’re entitled to? Contact us for more information.

Healthcare Payment Specialists

Healthcare Payment Specialists

Founded in 2002, Healthcare Payment Specialists (HPS) provides technology enabled solutions for health care eligibility, government reimbursement and compliance to hospitals and healthcare systems across the country. Using its STINGRAY software platform, HPS delivers solutions on a software-as-a-service (SaaS) basis or through outsourced service engagements.
Healthcare Payment Specialists