Auditing

No job is too small or too large. We will audit all the placements against their contracts to determine the payors are paying correctly according to contract. It is difficult to maintain all requirements to ensure proper payment has been made by all payors. This is a very time consuming task and with budget and staffing constraints it is one that often over looked by hospitals and medical facilities that tend to rely on software to automate the process by calculating the correct reimbursement for each payor.

Auditing Process

auditingOur auditors will review all pertinent information regarding each payor, managed care contracts, and any addendum’s that may be paramount to obtaining reversal of an earlier denial and/or partial payment. We will commence this analysis upon notification.

This review will produce the following:

  • Identification of accounts not paid according to contract;
  • Determining all services reimbursable by contract,
  • Provide guidelines and limitations to avoid denials and ensure proper billing.

Establish the Basis for Denial, Non-Payment, or Reduction of Payment

Excel will begin its efforts by requesting reconsideration of the claims and a written explanation of why the claim was denied, not paid, or not paid in full from the payors. Our auditors will then gather any other information needed to complete the process. They will then thoroughly research all areas of the accounts and re-bill the payors for any payment errors and discrepancies they find. As part of the process the hospital or medical facility will receive a detailed report of all the accounts that have been re-billed along with our expected reimbursement.

This will provide you with:

  • A negotiation tool when renegotiating contracts with payors
  • Serve as a benchmark to let you know the payors that are paying and the ones that are not
  • Identify Administrative Denials vs Clinical Denials

Excel’s auditing process will assist you in obtaining proper reimbursement for claims that were not paid for various reasons.
Some of these include:

  • Carriers paying late;
  • Outliers and
  • Stoplosses
  • Authorizations issues
  • Claims not meeting Medical Criteria
  • Carveouts missed
  • COB

The audit will provide and innovative solution to your placements.
By identifying the course of action required on the claims analyzed against the contract.
Our process includes:

  • Appeals and Denials
  • RN Medical Records review
  • Processing and collections of denied, and partially paid claims
  • Collections of claims that are denied due to contract issues.
  • Collections of untimely filed claims
  • Collections of catastrophic claims that have not been reimbursed per contract
  • Short paid implants and pharmaceuticals
  • Underpaid out-patient surgical procedures
  • Review and identify unpaid clean claims based on the carrier’s refusal to pay per contract. These claims will be forwarded to the Director for possible arbitration or legal action.

Yes We Are Different

differentWe audit every single account against your contracts. We want to make sure that the placement amount is the correct amount owed to the hospital or medical facility according to contract. Excel works as an extension of your facility, nothing slips through the cracks.