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Case Studies > Blue Cross Blue Shield

Titan Health Collects $6 Million in 2023 for Mid-Size Arizona Hospital System Due to BCBS OP Reimbursement Policies

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Key Takeaways
  • Because Blue Cross Blue Shield of Arizona has their own billing and coding guidelines, some of their reimbursement requirements deviate from that of conventional industry norms and CMS logic. This means that Arizona hospitals are at risk of not being appropriately reimbursed.

  • Titan Health engaged with a separate hospital system in Arizona and identified $6.3 million in underpayments in the first 60 days of working on this engagement.

Background

Blue Cross Blue Shield of Arizona does not always follow the conventional industry/CMS billing and coding norms, which means Arizona hospitals are at risk of not reimbursed appropriately. To measure its effect, Titan Health engaged with over 20 hospitals in Arizona to conduct a BCBS analysis. 

Our most recent analysis, based on a limited dataset, resulted in average hit rates of almost 50% of the accounts sampled being eligible for additional reimbursement, and this was with most of the hospitals already having another vendor for zero balance in place. 

 

The hospitals missed it, the zero balance vendors missed it, but we found it. 

The Challenge

Most reimbursement auditors are unaware of the opportunities available to accurately collect what is owed, and it’s extremely easy to miss. One of the largest nonprofit health systems in the state was concerned that they were not being reimbursed for all services rendered and as their contract intends.

The Solution

Aware of BCBS Arizona-specific opportunities, Titan Health reimbursement auditors focused on 3 specific areas to quickly collect as much money as possible:

  • Outpatient Surgery

  • Denials for COB or other patient information being needed

  • Emergency Room visits 

  • Missing charges and/or down-coded procedures

The Results

Working with the mid-sized hospital’s revenue team, Titan Health collected $6m in 2023. When we engaged with another hospital system, we identified $6.3m in underpayments in the first 60 days of the engagement.

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