A regulated process
Various state and federal laws protect healthcare providers and their
"entitled" revenue against inappropriate handling of Medicare and
commercial claims by insurance companies. In other words, it's safe
to assume that your facility shouldn't be receiving less than the
reimbursements you expected to earn on the date you rendered
those services to the patient.
A benefit denial is considered anything less than the contracted rate
or clearly specified out-of-network benefit rate (for example, 60% or
70% of the total cost), taking into account any patient deductibles and
reported co-insurance. A refund demand or recoupment is also con-
sidered a benefit denial. In fact, the No. 1 denial in recent years is the
"retroactive denial" that's then followed by a takeback demand by the
payer.
Insurance companies tend to handsomely incentivize recovery
departments and third-party auditors to find overpayments and issue
refund demands. This is how it usually works: An insurer notifies the
facility and other providers of an alleged claim review, or it sends a
request to review numerous medical records. This is then followed
with aggressive repayment demands using fabricated allegations,
ambiguous adjudication errors and misleading insurance policies.
Regardless of whether the payer is contracted with your facility,
there are explicit requirements that they must meet when it comes to
denials and requests for recoupment. For example, when issuing a
denial, payers must notify providers of their appeals rights, a require-
ment that often gets ignored. Paying close attention to the denial and
recoupment process may help your facility catch these missed prereq-
uisites, providing more opportunities to protect your revenue.
A P R I L 2 0 1 6 • O U T PA T I E N TS U R G E R Y. N E T • 3 3
