Challenge
A large regional health system with $1.8 billion in net patient revenue partnered with PCS to ensure they receive the revenue they are contractually due. The health system suspected they were being underpaid, but needed support identifying areas for improvement and a safety net to ensure maximum recovery of underpayments.
Solution
Through analysis of payer agreements, use of proprietary contract modeling technology and root cause analysis, PCS’s subject matter experts uncovered millions of underpaid dollars across the health system.
PCS Underpayment Recovery identified a subtle readmission billing process error for state Medicaid claims that had significant impact on revenue. PCS obtained a timely filing waiver from the payer to capture the historical loss and redesigned the billing process at the health system to prevent the issue from occurring going forward.
PCS Underpayment Recovery also identified a substantial payer’s payment policy that conflicted with the health system’s payer agreement. PCS worked directly with the managed care payer to correct their system to prevent future underpayments and secured a timely filing waiver to recover the historical loss.
Results
By implementing PCS Underpayment Recovery, the health system currently benefits from a 99.7% revenue capture rate. In the first six years, over $45 million in revenue was recovered. Through partnering with PCS and implementing root-cause recommendations, the health system’s underpayment exposure rate has reduced by 45%.
Ongoing engagement with PCS’s underpayment experts ensures compliance with complex reimbursement structures and continued
process improvement.
Financial
$45M
identified over six years
Operational
45%
reduced underpayment exposure
Continuous improvement
$7M
benefit from root cause analysis
