Managed Care Payer Audit System

The regrettable reality of the state of both hospital and managed care payers claims processing/remittance posting systems is, often times, not quite reflective of the computer system capabilities that are available in today’s environment. Although there is no shortage of firms that will come in retrospectively to identify and collect underpayments over the period of the State specific statue of limitations (5 years in many states), of which DMS is definitely one, it makes more financial sense for hospitals or hospital systems to have access to a secure, very flexible, HIPAA compliant hosted application that can simply periodically read in the hospital patient accounting, decision support data, model any contract term that is possible of being negotiated, and identify any underpayments within a month of receipt/posting of the remittance, including the payer specific adjustment codes, and addressing the underpayment on a more or less real time basis.

Are there separate, standalone systems that one can purchase to perform the same function; absolutely; do they require a large capital outlay and the additional fixed costs of hiring several employees to run and maintain the system.

DMS has already developed a secure, hosted application that can read in most mainframe systems patient accounting and decision support data feeds with minor modifications, so no large capital outlay. The system requires no additional fte’s to operate and automatically produces reports/views that any authorized viewer can see (including the payer) to resolve any payment dispute. In addition, we load in the applicable contract document so that both parties have all the information available to re-adjudicate the claim, and, if necessary, even view a digitized view of the remittance. The system is available for a monthly leasing payment that will pale in comparison to the contingent fees payable for a multi-year retrospective review.