managed care payment reviews

Triage specializes in Managed Care Payment Review. We audit HMO, PPO, Managed Medicare, Managed Medicaid, Workers' Compensation, and any other health plan governed by a contract or fee schedule, in order to ensure that our clients receive full reimbursement. These reviews have recovered over $1 billion for more than 200 clients. Three project objectives drive our review:

  1. Identify and recover underpayments

    2. We add cash to the bottom line. Triage systematically reviews patient accounts for payment accuracy and recovers underpaid cash, interest and penalties from health plans.

  2. Minimize risk of future cash loss

    3. We identify the mistakes which contribute to payment errors. Over the course of the project, we meet regularly with hospital staff and recommend specific policies and procedures to reduce the likelihood of repeating the error. We customize trainings for each hospital.

  3. Provide information for future contract negotiations

    4. We improve the quality of future revenue. Triage systematically reviews health plan contracts and makes recommendations to upgrade hospital contracts to industry best practices.

No financial investment is required, and our fee is based on the total amount of underpayments we collect over the course of the project. Triage has recovered significant underpayments for our clients – significant sums they did not even know existed.

THE TRIAGE PROCESS

We receive a selected download of patient account activity from a hospital's information system (typically two years of data). Triage then reviews zero balance patient accounts (receivables) in conjunction with detailed contract analyses, to ensure payments received are in accordance with the terms of the managed care contract or fee schedule. This is performed independently of the hospital’s expected reimbursement system.

When a health plan’s payment is not in compliance with the contract, we identify, analyze and recoup the underpayment. Triage works directly with insurers, PPOs, employer groups, third-party payers and/or government entities to collect what is rightfully owed. Upon resolution, cash is sent directly to the hospital. In this way, Triage helps clients see immediate and increased cash flow.

Each project is staffed with an expertly trained team consisting of a Principal, Manager, Senior Associate, and as many Associates as the project requires. Throughout the project, we report major findings and recommendations to senior management, the business office, and contracting personnel. At the conclusion of our fieldwork, we present a detailed report of findings and recommendations.

OUR PROMISE TO OUR CLIENTS


"Maximum Reimbursement. Minimum Disruption. Zero Investment."

"We hardly knew they were there until the cash started coming in the door.”
- Cindy Riedel, HCA

Maximum Reimbursement: If it is there, we will find it. The Triage staff is expertly trained to discover underpayments that occur in the hospital setting. Since we started, Triage has identified and recovered over $1 billion in underpayments. We derive virtually all of our new business from satisfied customer referrals.

Minimum Disruption: Our clients hardly know we are there. Our goal is to achieve the client’s project objectives working invisibly and independently. During a project, Triage is especially sensitive to our client’s work environment and does everything possible to ensure minimum disruption of daily operations. We utilize our own resources, not our clients’.

Zero Investment: We invest ourselves in the success of every project. We base our fees on the total amount of underpayments we collect. Our typical fee structure is a contingency rate. This fee includes training the client’s staff to be self-sufficient in identifying underpayments.

For more information on how we may be of service to you, please contact us at 415-512-9400 or email .