Payment Auditing

Once upon a time, the negotiation of a managed care contract was the hardest part. Now, making sure that you are being paid according to the terms of the agreement is equally important.

With many services reimbursed at fixed amounts (e.g., DRGs; per diems; rates per case, visit or unit; lab, radiology and professional services fee schedules) rather than a percent of charges, the opportunity for a payer to make a mistake is great. And then there’s the confusing rock-paper-scissors hierarchy of payments (e.g., reimbursement for emergency department services is rolled into the outpatient surgery case rate if the patient is admitted for surgery from the ED).

Managed Care Partners will assist in the verification of payment accuracy and timeliness. The purpose of the verification process is to a) identify the claims where the payer’s allowed amount is different than the contract’s rate and b) compile the data necessary to appeal any payment errors. Often, this begins with a sampling of several commercial and Medicare Advantage payers’ claims, which then moves to an in-depth examination of claims for those payers who fail the initial sampling.

If we are providing ongoing services for our Managed Care Department and Integrated Provider Networks clients, the sample verification is included in the monthly fee. We will also examine all claims for all commercial and Medicare Advantage payers on a quarterly basis. The cost for this in-depth review is based on the number of payers, expected claims volume, the fee structures within the payer contracts and the availability of electronic claims data files from the provider.

Managed Care Partners, Inc.

875 N. Addison Avenue

Suite 200

Elmhurst, IL 60126

630.936.4211 - phone

630.617.4222 - fax

Additional locations:

Beaufort, SC

Galesburg, IL