KBH Analysis Services
When first encountering managed care issues in the rural or small community hospital, the most frequent comments we hear are something like: "that doesn't make any sense" or "we were expecting the opposite result from what we got" or "the MCO promised us that . . . "
Managed Care
Impact Analysis . . .
A Science or An Art?
Analysis of the expected impact of Managed Care issues is a bit of both. We’ve all asked ourselves “Is this reimbursement level acceptable?” “How will it impact my bottom-line?” “How do I know if I’m leaving anything on the table?”
Knowing what to offer, what to accept, and what to reject requires extensive behind the scenes number-crunching and evaluation, which is one of KBH's specialties.
KBH provides expert analytical services to support providers in their managed care activities. Some of those analyses include:
- Financial Modeling
- Claims Denial Management
- MCO Claim and Chart Audits
- MCO Charge Increase Audits
- Unilateral UCR Application
- Managed Care Options for Local Employers
- Charge Item Pricing Impact Analysis
Financial Modeling
Accurate predictions of reimbursement are critical to the providers' financial success from both existing and proposed managed care contracts. KBH modeling analyzes all relevant options of reimbursement methodologies to determine each of their estimated impacts upon providers.
Making this task more difficult each day, MCOs constantly change their reimbursement methodologies, often doing so unilaterally, without explanation or definition within the written contracts and/or provider manuals.
KBH has the knowledge and technical capabilities to analyze any methodologies proposed by an MCO, including DRG, per case, per diem, APC, ASC, procedure specific, and fee schedule based. Stoploss criteria and lesser of charges impacts are also factored into the analyses. Results are provided on overall weighted basis and specific department, clinical service area, or provider specialty.
Claims Denial Management
Managed Care Organizations (MCOs) spend millions each year to find new reasons to deny or underpay claims, or to delay payment. As a result, providers are not collecting large portions of the revenue to which they are entitled.
Effective denial management requires both proactive denial avoidance and effective appeals. Each appeal costs money and even with the most advanced claims management computer systems, some critical claims will require “human” intervention.
Let KBH utilize its expertise in claims management to increase your manpower, save your business office staff time, and eliminate costly outstanding or inappropriately denied claims.
MCO Claim & Chart Audits
Medical records contain a wealth of data useful for many purposes to various groups.
However MCOs are increasingly auditing medical records to enforce providers' adherence to coding standards based upon the MCO's procedures and criteria. If not complied with, documentation in the medical records is being used by MCOs to deny claims, accusing providers of inappropriate bundling or unbundling of codes, thereby causing significant negative financial implications upon the providers.
Don’t just “accept” their findings – your money is worth fighting for. Let KBH assist your organization in verifying the accuracy of the audit findings, determining the appropriateness and relevancy to the coding procedures agreed upon by the contract, and establishing effective arguments for appeal.
MCO Charge Increase Audits
As MCO’s continue to insist upon including charge increase limiters in their contracts, providers should expect the frequency and intensity of these charge increase audits to grow.
The cumulative effect of providers mistakenly acquiescing to past findings of increase violations by the assigned auditors can have devastating compounded negative impact on future audits.
Providers must ensure the accuracy of each audit’s findings.
Having worked with many of the auditing companies used by payors in a collegial and professional manner for many years, KBH consultants are knowledgeable of most approaches utilized by auditors, and have a highly successful track record finding objective data from reliable outside resources that can have an impact of reducing and even eliminating audit refund requests.
Let KBH assist your organization in verifying the accuracy of the audit and establishing appropriate arguments for your appeal. KBH assistance can be behind the scenes providing your executive team with valid objective arguments to suppot your position. Or, KBH consultants can do both the analysis and the representation of the provider’s interests at the negotiation table.
Unilateral UCR Application
It is becoming increasingly common for providers to have claims adjudicated by unilaterally applying Usual, Customary & Reasonable (UCR) standard charges over and above the contracted discounted rates, resulting in inappropriate reimbursement levels.
What isn’t openly discussed is that the “standards” are created by for-profit corporations which are neither “independent” nor “disinterested” third parties. In fact the largest distributor of what has been termed by providers as “Automated Claims Denial Software” is none other than the second largest insurer and MCO in the nation.
Even if the MCO claims it is paying “according to the contract”, you must objectively verify the accuracy of the UCR application and establishing appropriate protocols and arguments for appeal.
Managed Care Options for Local Employers
Employers are seeking answers to their ever increasing costs of healthcare coverage and administration. They are as frustrated by managed care issues as are the hospitals and physician.
Providers in small communities typically know all the local area employers on a personal basis. Their kids play soccer together. The human resources director is a neighbor of the hospital's lab director. These close personal relationships offer great opportunity for the community at large.
It is important for providers to enlist the employers, the public, and the insurance brokers in a mutually cooperative effort to make the managed care initiatives work for the community's best interests.
Working together closely with hospital administration, KBH consultants can analyze the opportunities present to elicit that cooperative approach.
Charge Item Pricing Impact Analysis
Budgeting hospital and physician revenues is more complex an issue than in any other industry. Healthcare providers typically do not know until the end of the year how accurate their projections have been, with wide swings in the numbers being possible.
Hospitals have to not only project how many clients they will have in the coming year, but also the nature of each visit to the hospital. Additionally, each patient visit, even if for the same general procedure as other patients, could require vastly different treatment protocols depending upon the patient's individual needs.
The typical hospital has as many as 20,000 separate charge items for which the hospital must estimate a usage number for the year, and the expected cost to provide each unit.
To perform due dilligence in the budgeting process, the hospital must have as many as 20,000 separate pricing projections. As can be imagined, this highly complex process requires experienced and fastidious technicians, with strong computer assistance to weigh all the possible options, and to decide on the appropriate answers.
KBH consultants are accustomed to juggling 20,000 balls in the air while determining relative pricing which maintains fiscal integrity. Whether the hospital budgeted revenue is $20 million or $800 million, KBH consultants have the talent and experience required to have full assurance the hospital's financial needs will be met.