States using the ED Triage payment methodology by Medicaid and Managed Medicaid payers often have hidden and challenging reimbursement opportunities.
THE CHALLENGE:
- High volume, low dollar accounts, which staff does not have the bandwidth to pursue or sees as low priority.
- Confusing or absent denial codes shown on EOB do not indicate the reason for the lower payment, nor the information about the opportunity to provide documentation for additional reimbursement
- Outsourcing low balance vendor does not manage these accounts as clinical denials or have a working knowledge of ED Triage payment methodologies from Medicaid or Managed Medicaid payers
- Some hospitals are unaware of situation or accept triage payments only – forfeiting a significant amount of revenue
THE SOLUTION:
- Streamlined process to appeal these denials within short timely filing deadlines.
- Expert knowledge in Medicaid and Managed Medicaid methodologies of all affected states
- Technological and clinical staff expertise that can work these low dollar, high volume claims in a fast and efficient manner
- Proactively recognizing opportunities, issues, and trends to make immediate adjustments
- Generate meaningful performance reports that provide clarity on accounts that can be overturned
- Attentive nursing staff who identify patient’s who frequently visit the ED and work with insurance case manager to help the patient find a PCP, which will help to reduce unnecessary trips to the emergency room
Revenue integrity is vital for hospitals in an ever-changing healthcare environment. It has become necessary to have a solid process in place or to work with a vendor that has the expert knowledge and high success rate as another component in the revenue cycle continuum.
