This pain management practice had adjusted (i.e. written off) approximately $300,000 in revenue for preventable reasons. The root causes can be broken down into the following categories:
Blue Cross WA & AK Premera claims rebilled to correct Insurance/plan type after initial denial that can be prevented. 948 claims rebilled to Blue Cross in the last two months. This represents a significant increase in cost due to “re-working” the claims.
The practice took a more proactive strategy by using Gentem’s Real-Time Eligibility (RTE) feature. The practice eliminated rebilling with GentemRTE by identifying and flagging inaccurate insurance plans ahead of time before the practice submitted claims.
The practice’s physicians received a negative adjustment on Medicare E/M services due to a negative MIPS adjustment.
Certified Gentem Advisors assist the practice managers in realtime on MIPS attestation and submission of measurements.
Gentem identified payments received between January to August 2019 that were posted on October-December 2020.
The practice established clear metrics and processes using the Gentem Dashboard for a streamlined workflow. This system helped better define timelines for payment postings. Payments were then posted within two days of receipt and monthly payment reconciliation. They were able to identify missing payments with follow-ups using check tracers.
We will be able to advance 85% of the contracted allowable. An analysis over the last two months shows an estimate of what Gentem would have been able to advance. Of note, Gentem only advances insurance reimbursements, not patient responsibility.
|Month||Week||Claims||Charges||Allowable||Estimated Advance Payments @ 85%|
Gentem will review the ‘Medical necessity’ and ‘Insufficient documentation denials’ in order to provide solid recommendations to the practice. These are to prevent claim denials and improve clinical documentation.
Keeping up with the latest updates and market changes helped the practice continue to adjust and thrive. Gentem advisors provide ongoing educational updates by outlining the latest in payer policies to prevent medical necessity and insufficient documentation denials.