High-Dollar “Outlier” Claims

High-Dollar "Outlier" Claims

FlexPoint can help you achieve timely adjudication and maximum reimbursement for Outlier claims.

Issue

Insurers will do everything they can to minimize reimbursement reimbursements to healthcare providers for Outlier claims. During Pre-Payment review, their computer systems automatically flag Outlier claims as having “errors.” Once a claim is flagged, they will route the claim to a “specialized clinician” (who works for the insurer) to find “problems” with the claim. This leads to sending the claim back to the provider for reconsideration which usually results in less reimbursement or claim denial altogether.

Common adjustment categories include:

Consumption of supplies and services
Hospital-acquired conditions
Plan benefit coverage
Implant markups

One insurer boasts on their website that their itemized review of high-dollar claims saves them an average of $11,000 per claim. They calculate that this equates to 10% average per-claim savings.

Solution

Without a team dedicated to reviewing and monitoring the adjudication of Outlier claims, undetected issues will cost a hospital millions of dollars per year.

FlexPoint can save you a lot of time and money by reviewing and monitoring 100% of your Outlier claims. We will challenge every claim that is improperly or unfairly adjudicated by insurers. As soon as an Outlier claim is submitted to an insurer, FlexPoint will automatically perform an initial review of the claim and calculate the expected reimbursement per the underlying contract terms with the insurer. FlexPoint will then begin to track how the insurer actually adjudicates the claim. The insurer can decide to pay the claim in full, reduce the amount to be paid, hold the claim, or deny the claim. No additional follow-up is necessary if the insurer pays the claim in full. However, immediate action must be taken through Recovery procedures if the insurer reduces the amount to be paid, holds the claim, or denies the claim.

Pre-Payment Recovery

“Negotiations”

On your behalf, FlexPoint will work directly with the insurer to investigate claims that have been adjudicated with reduced payment amounts (but prior to actual payment), have been placed on hold, or denied. FlexPoint strives to informally resolve issues on initial contact with the insurer whenever possible. Most claim issues can be remedied quickly by providing the insurer requested or additional information for denials related to timely filing, incomplete claim submissions, and contract / fee schedule disputes. If issues cannot be resolved informally, insurers normally offer two options:

An appeal process for resolving contractual disputes regarding post-service payment denials and payment disputes. Processes may vary due to state mandates or contract provisions.
For claim denials relating to claim coding and bundling edits, a healthcare provider may have the option to request binding external review through a Billing Dispute Administrator.

Post-Payment Recovery

“Appeals & Arbitration”

This recovery procedure occurs Post-Payment which means after the provider receives some payment for the claim. Or, the claims are still placed on hold, or denied.

On your behalf, FlexPoint will file Appeals and/or submit for Arbitration any disputed claims that have not been fairly resolved through Pre-Payment Recovery efforts.

If an Appeal is unsuccessful, Arbitration may be used as a final resolution step. If an arbitration provision was placed in your healthcare provider agreement, the terms and conditions of that provision will apply. If your healthcare provider agreement does not include an arbitration provision, the appealing party prepares a Request for Dispute Resolution list and submits it to an independent 3rd party Alternative Dispute Resolution (ADR) service.

FlexPoint will handle the entire Appeal and Arbitration process.