impact story

Automating Analysis of Payer Performance Resulted in $100,000 Saved in Recoup

Unable To Track Underpayments and Address Unfavorable Variations

Health systems across the U.S. have been on a growth spree. Acquiring or merging with other organizations can result in economies of scale that can be leveraged in negotiation with payers and vendors, but it can also incur significant financial risk. During the transition phase of forming the new organization, there are often multiple information systems and business units running in parallel. Big problems can easily go unnoticed. The result: lost revenue, unchecked expenses, and negative impact to the bottom line.

Like many health systems across the country, this integrated delivery system in the southeast has grown rapidly through acquisition. Almost 12 months after the acquisition, a major payer realized they had been inadvertently paying the newly acquired hospital at the larger, tertiary care hospital’s rates, which were significantly higher. Rather than to offer a take-back, the payer decided to reduce the rates of reimbursement for the system over the following year. The payer proposed a reduction in rates that seemed on-par with the overpayment, but the organization needed to determine whether this offer would impact their reimbursement.

This organization drove results and impact

Quickly modeled true impact of payer’s rate on reimbursement

Recouped $100,000 in potential lost revenue through true-up with payer

Expects to gain or recoup additional ~$500,000 within the fiscal year

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