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SERVICES
Despite initiatives to standardize and streamline, healthcare reimbursement has continued to increase in complexity and as a result, 2-3% of net patient revenue can be underpaid. The ultimate root causes for these underpayments are varied, running end-to-end in the revenue cycle, and include errors on the part of both the payers and hospitals. The end result is lower reimbursement driven by incorrect payment by the payers and inconsistent coding on claims.
Resource constraints, both technology and labor capacity, can often make these underpayments difficult to identify and recover. Through the application of proprietary technology solutions coupled with deep subject matter expertise, Cura's Underpayment Recovery Services deliver a comprehensive set of solutions targeted to maximize recoveries and minimize revenue loss.
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UNDERPAYMENT RECOVERY FOCUS
SOLUTION AREAS
Payment Integrity
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Review of all accounts to identify, verify and recover underpayments where the payer did not pay the appropriate amount owed to the hospital based on the claim submitted and applicable payer contract or reimbursement terms. Key features include:
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Proprietary contract modeling software has the ability to calculate complex contractual terms with unparalleled accuracy and automatically identify underpayments
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Utilizing actual 837 and 835 data sets, our software platform simulates the claim adjudication process used by the payer to identify discrepancies
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Using proprietary software that leverages artificial intelligence and machine learning algorithms, our software is able to merge real-time denial trends with underpayment calculations
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Detailed reporting allows for the assessment of issues by underpayment type, types of service, payer trends, contract load errors and contract interpretation issues
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End-to-end solution includes appeal and follow up steps with the payer required to receive additional and correct reimbursement
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Billing & Coding
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Analyze all claims to ensure that the coding and billing practices are consistent with payer requirements and accurately represent the services provided to the patient. Key features include:
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Proprietary analytics software which evaluates all claims against EMR data to identify underpayments resulting from billing and coding discrepancies
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Comprehensive review includes all payers and service types, including complex cases not supported by traditional software and processes
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Certified coders provide evidence for each recommendation and coordinate with HIM and Compliance departments to provide supporting documentation
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Ongoing billing and coding analysis driven by industry and provider specific updates ensures comprehensive coverage
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Data driven consultation identifies root cause issues and strategies for prevention
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IMPLEMENTATION
Cura understands that hospitals deploy multiple internal teams, software applications and external vendors to support their revenue cycle efforts. In many cases, hospitals are successful at using these resources to identify and correct problems early in the revenue cycle process. As a result, Cura typically reviews accounts upon reaching zero insurance balance and begins with a two-year retrospective review. Following the retrospective review, Cura works with each client to ensure that the ongoing accounts which reach zero insurance balance are monitored for future underpayments. Depending on the timely filing limits imposed on each hospital, Cura will customize the implementation to minimize the likelihood ongoing underpayments are lost due to age.