“The practice saw a benefit in having a third party examine our contracts and payments.”
identify late payments and underpay- ments to health professionals, including physicians. Dr. Breeze hopes that as more physi- cians use these kinds of auditing servic- es, insurance carriers will adhere more closely to prompt pay regulations and perform better overall. “My experience is that payers improve immediately following an analysis, but over the next year or so, payment prob- lems start cropping up again. I think medical claims complexities contribute to late payments and system-wide lapses on the part of the payers,” Mr. Reynolds said.
provided by the prompt pay statute, that one payer could owe the practice more than $2 million,” she said. During their analysis, nVenio auditors
discovered the payer had given the prac- tice a fee schedule that didn’t correspond to the one agreed to in the contract. “I requested the fee schedule on a CD
from the payer so that I could load it into our practice management system. I thought we were being paid correctly for two years, but it turned out we were receiving rates that were incorrect com- pared to the rates we’d negotiated in our contract,” she said.
Richmond Bone and Joint Clinic —
now part of the Memorial Hermann Health System — has an arbitration meeting with the payer in January. “We’re still sorting out the recovery
process. I can safely say that had I not hired nVenio, we wouldn’t have uncov- ered the egregious payment errors and wouldn’t be pursuing the money we’re owed,” said Dr. Breeze.
Payment errors, violations abound Bill Reynolds, nVenio Analytics found- er and chief operating officer, says he helped medical practices recover more than $20 million in prompt pay and contract violations from 2003 to 2012. That includes inappropriately bundled and downcoded claims, in addition to delayed payments and improperly dis- counted payments from third-party ad- ministrators. Mr. Reynolds helped one
58 TEXAS MEDICINE August 2013
12-physician orthopedic practice in Tex- as recover about $2.5 million in prompt pay penalties from four payers. While not every analysis yields such lucrative recoveries, Mr. Reynolds says the initial, in-depth analysis of a prac- tice’s past four years of claims is valu- able in more ways than one. Following the analysis of a practice’s financial data and the resolution process with payers, nVenio focuses on educating physicians and helping practices improve their bill- ing and collections processes. “One of the things we find is that a practice’s billing system typically isn’t configured in a way that helps the prac- tice to monitor and expose prompt pay violations. Claims paid 31 to 45 days late may not be getting flagged. We can help practices use these systems better to help them stay on top of late pay- ments and penalties owed,” Mr. Reyn- olds said. Dr. Breeze says she learned a lot from the analysis.
“Now I never take any information given to me from a payer at face value. I triple-check that the information is cor- rect and is what was promised to me,” she said.
Justin Demerath, an attorney with
Austin-based law firm O’Hanlon, Mc- Collom & Demerath, says that in his experience, prompt pay violations are commonplace in most medical practices. The firm uses specialized software, de- veloped in conjunction with its litigation partners, to analyze insurance claims to
Physicians seek outside help Combing through four years’ worth of claims and memorizing contract terms are neither feasible nor realistic tasks for the majority of medical practices. That’s why many physicians turn to in- dependent auditing firms to delve into how they’re being paid. Both nVenio and O’Hanlon, McCollom & Demerath have processes for holding payers accountable to the prompt pay law. Dr. Breeze encourages physicians to
have an outside company perform an in-depth audit of payer contracts and claims data. “That initial, comprehensive analysis shows medical practices how they’re faring with each payer. We were able to identify which payers were performing well, paying us correctly and on time, and which payers had deficiencies, vio- lating the prompt pay law and underpay- ing,” she said. To determine whether commercial payers comply with the prompt pay law, nVenio analyzes payer contracts and examines the fee schedules. Its audit- ing technology extracts all encounter, patient, insurance, claim, payment, and collection data from the practice man- agement system.
After analyzing claim submission and payment receipt verification, along with other information, nVenio gives physi- cian clients a breakdown of all late and underpaid claims plus a calculation of prompt pay penalties. Once nVenio identifies a practice’s underpayments and penalties, it begins
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68