Case Studies > Zero Balance Case Study

Headline goes here - eg: Midwest health system boosts collections by recovering $2.9 million in lost revenue and improves processes to prevent future underpayments. 

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Overview

Our client is a premier integrated academic health system located in the Midwest. The system consists of a nationally recognized School of Medicine, 10 hospitals, and a medical staff of more than 4,000, including more than 1,000 residents and fellows and over 1,500 employed physicians.

The Challenge

The health system presented Titan with two specific challenges. The first - identify the scale of the suspected underpayment problem and recover the lost revenue quickly. The second - identify the root cause and then determine the remedy needed to prevent the problem from continuing.

The Solution

The health system engaged Titan’s Zero Balance Audit Team to rapidly diagnose and resolve a critical and expanding underpayment problem. A review of the UHC contract by Titan auditors revealed that the health system’s Charge Description Master (CDM) had been loaded with certain revenue code/CPT code combinations that were incompatible with UHC reimbursement policies. This resulted in hundreds of claims being processed and paid incorrectly.

 

Upon further analysis, Titan determined that when certain revenue codes were billed, the facilities were only being reimbursed for supporting services, such as labs, and not for the main services of the visit. Specifically, UHC deemed the primary service “not separately reimbursed” when billed with other services that were being paid using “Per Visit”, “Per Case” or “Per Unit” reimbursement methodology.

Through a collaborative process, health system improved fundamental billing processes to prevent future underpayments.

Audit Revealed CDM Configuration Triggered Bundling:  The audit revealed that the hospital’s CDM was billing out the supporting services with revenue codes that triggered a bundling denial. The audit also discovered that the revenue codes being used were not the only available option per CMS guidelines.

Titan Identified Correct Revenue Codes and Requested Rebill: Supported by the available medical records, Titan submitted requests to the PFS team to correct the revenue codes that had caused the bundled service claim denials and resubmit the claims. This resulted in UHC paying all services at the intended rates.

Titan Collaborated With Client to Correct CDM: Titan staff worked closely with the health system’s CDM team to identify the individual CPT code/revenue code combinations that were causing the payment errors. This included identifying which revenue codes could be added to the CDM to prevent the underpayments from happening in the future.

The Results

Working together with this health system, Titan was able to recover $2.9 million in underpayments spanning 970 patient accounts and correct the client’s CDM configuration to prevent future underpayments.

By the Numbers

970

Volume of affected accounts identified

$2.7 Million

Total underpayments Identified
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