Healthcare
Situation
Dominant regional healthcare payor in billing dispute with globally renown healthcare facility that continued for 2 years and total dispute amount of $56M. Each party agrees to arbitration to resolve the ongoing issues.
Task
Construct a data-based and revised medical coding manuals procedure approved by both parties. Audit each party’s medical charges accounts outstanding.
Action
Staffed a multi-disciplinary team of medical coding, billing and dispute procedure professionals then split into A / B teams to audit each party. In real time, reconciled the chronological record(s) of billing, disputes, payments (partial and/or complete) and outstanding co-pay amounts.
Result
Facility received $14M in overdue and correctly coded payments. Payor was relieved of $27M incorrectly coded or otherwise outside policy payments to Facility. Each party was relieved of $12M in inaccurate or otherwise unsupported claims and erroneously attributed co-pays. Relationship repaired, all accounts current, new dispute resolution processes embedded.
