Three Effective Solutions for Recovering Missed Revenue

It’s no secret that 2022 was the worst financial year in history for hospitals, health systems and physician groups. The good news is that there has never been a better time to identify and recover missing revenue that is available to your healthcare organization.

 

Three Key Opportunities for Identifying Missed Revenue

 

With a little work, healthcare organizations can identify and collect critical cash. In this article, we’ll examine three areas that healthcare organizations tend to overlook when it comes to revenue:

• Government Reimbursement
• Zero Balance Review
• Federal and State Charity Programs

 

Government Reimbursement

 

Nearly every U.S. hospital with Medicare, Medicare Advantage and other uncompensated care (S-10) reimbursement claims is missing at least $1M+ in uncollected revenue. Why is this the case?

 

Medicare alone provides reimbursement for $3.5B per year to hospitals for Medicare bad debts, but most U.S. hospitals under-report their Medicare bad debts by an average of 6% to 7% every year.

 

Tips

 

Even with a vendor or process for creating cost reports in place, most providers can use a second look into their cost report and bad debt data. To locate missed revenues from government reimbursement areas:

• Perform a thorough “look back” on your Medicare, Medicare Advantage and other uncompensated care (S-10) claims and their associated accounts
• Amend the cost reports as needed
• Resubmit the bad debt logs so your organization can retrieve this previously unreported reimbursement

 

Hospitals typically uncover upwards of $1M in uncollected revenue from government reimbursement sources when they perform a review of their cost reports and bad debt logs.

 

Fiscal intermediaries are closing cost reports at an accelerated pace, so the time to act is now. Be sure to review previous years’ cost reports and bad debt logs as well.

 

Zero Balance Review

 

Your healthcare organization could be leaving money on the table from patient accounts that may have been incorrectly paid by the health plan or government fee schedules. Approximately 7% of paid medical claims were found to have errors, and denied claims averaged about 5%, according to recent data from the American Medical Association.ⁱ

 

To retrieve all of the money owed to your organization, review unpaid and underpaid balances from closed patient accounts from all types of payers, including government, commercial and self-funded. On average, most hospitals are able to identify and collect 1% to 2% of their net revenue in additional collections from closed patient accounts.

 

Tips

• Analyze the last 6 to 12 months of data for closed claims
• Compare paid claims data to payer contracting obligations
• Pursue variances with the payers to pay the hospital the full owed amount
• Review policies, procedures and contract language in order to improve future claims payment accuracy

 

For a $250 million hospital, an additional 1% to 2% of found revenue means $2.5 to $5 million in additional cash added to the bottom line.

 

Federal and State Charity Programs

 

The federal government’s “continuous enrollment provision,” which was part of the Families First Corona Virus Response Act that went into effect in March 2020, has now ended. As a result, millions of people with Medicaid have seen their eligibility change primarily due to changes in income, and some enrollees are being dropped for “procedural termination.”

 

For example, in April 2023, 72,802 Arkansas residents were dropped from the state’s Medicaid program because they failed to return a renewal form that is now required. This population includes 28,000 children and infants.ⁱⁱ

 

Parents often do not realize that even if they are no longer eligible for Medicaid, their children may still be eligible for either Medicaid or the Children’s Health Insurance Program (CHIP). The time is now to review patient eligibility for Medicaid as well as additional state and private programs that may be available to the patient.

 

Tips

• Thoroughly review any patients who may have been dropped by Medicaid for changes in eligibility
• Designate a hospital representative to work with patients to complete a Medicaid application on their behalf, collect required materials such as tax forms and submit electronically
• If the patient is no longer eligible for Medicaid, take a look at the additional federal and state programs, such as CHIP, that they may be eligible for

 

Some states have as many as 50 federal and state charity programs for underserved patients.

 

Conclusion

 

It takes a little time and effort, or partnering with a vendor with expertise in the specific area, to capitalize on these opportunities. However, the financial gain for healthcare organizations that are struggling with thin margins can be significant.

 

ⁱ Becker’s Hospital CFO Report, There’s Gold in the Zero Balance Review, February 21, 2017, www.beckershospitalreview.com/finance/there-s-gold-in-the-zero-balance-review.html. Accessed 3.13.23.

 

ⁱⁱ Millions Will Be Dropped from Medicaid in Wake of COVID Provision, https://www.nerdwallet.com/article/health/managing-health-insurance/medicaid-unwinding. Accessed 5.30.23.