KBH provides expert analytical services to support providers in their managed care activities and knowing what reimbursement to offer, accept, and reject requires extensive behind the scenes number-crunching and evaluation – one of KBH’s specialties.
Analysis of Managed Care Issues is Crafted from a Bit of Both Science and Art.
Financial Modeling
Accurate predictions of reimbursement from both existing and proposed managed care contracts are critical to financial success. KBH modeling analyzes all relevant options of reimbursement methodologies including DRG, per case, per diem, APC, ASC, procedure specific, and fee schedule based to determine estimated impact on providers.
Employer Claim Audits
Unlike a financial audit performed by an accounting firm, KBH can examine the entire claims payment process with a goal to identify areas for operational process enhancement. The employer is then able to determine if claims are being adjudicated as the contract requires, as well as evaluate the administrator’s ability to meet defined administrative requirements.
Traditional KBH audits include a comprehensive electronic review of all paid claims using our electronic capabilities and proprietary claims audit logic to identify potential incidences of the most common payment errors. KBH can also design custom audit queries based on the particular experience and needs of the employer group.
Our experience includes work with major financial institutions, retail and hospital systems.
Claims Denial Management
Effective denial management requires both proactive denial avoidance and effective appeals. Let KBH utilize its expertise in claims management for both individual and systemic issues to increase your manpower, save your business office staff time, and eliminate costly outstanding or inappropriately denied claims.
MCO Claim & Chart Audits
MCOs are increasingly auditing medical records to enforce providers’ adherence to coding standards and risk adjustment factors based upon the MCO’s procedures and criteria. Let KBH assist your organization in verifying the appropriateness of the records request, the accuracy of audit findings, the relevancy of coding procedures agreed upon in the contract, and establishing effective arguments for appeal.
MCO Charge Increase Audits
Having worked with many of the top auditing companies used by payors, KBH consultants are knowledgeable of analytical approaches utilized by charge increase auditors. KBH has a highly successful track record of establishing appropriate arguments and supporting documentation for appeals to successfully reduce or eliminate audit refund requests.
Unilateral UCR Application
Even if the MCO claims it is paying “according to the contract”, providers must objectively verify the accuracy of UCR application and establish appropriate protocols and arguments for appeal.
Collaboration with Local Employers
It is important for providers to enlist local employers, insurance brokers, and the public in a mutually cooperative effort to ensure managed care initiatives promote the community’s best interests. Working together closely with hospital administration, KBH consultants can analyze the opportunities present to foster that cooperative approach.
KBH has seen a notable increase in negotiating direct contracts with locally based employers and religious organizations over the past 2-3 years.
Charge Item Pricing Impact Analysis
Providers must analyze tens of thousands of separate pricing projections. As can be imagined, this highly complex process requires experienced and fastidious technicians, to decide on the appropriate answers.
Whether the hospital budgeted revenue is $20 million or $800 million, KBH consultants have the talent and experience required to provide full assurance that the hospital’s financial needs will be met.