“Triage actually spent the time and effort and resources to dig into every single claim. Even to the point when they came up against a stone wall and they felt strongly about their position, they were willing to come to us. Here it is. Here’s your case. You want to sue them? Go ahead … which speaks volumes.”
- Ron Vaughn, Director, PFS Managed Care, Texas Region
CLIENT
Tenet HealthSystem
OBJECTIVE
Overturning denials and getting beyond, “no”.
CHALLENGE
Tenet engaged Triage to perform a managed care payment review of its Texas market hospitals. In the course of Triage’s review, the consultants found a significant area of payment errors from a large health plan. Triage alerted its client of its findings so that Tenet could be on the look out for similar issues within its current inventory of accounts receivable. Between the client’s own Patient Financial Services staff and Triage, underpayments accumulated over $1 million. The health plan denied all appeals for restitution.
SOLUTION
Triage met with Tenet’s legal department to discuss the denied claims. Triage’s presentation included the contract excerpt supporting the basis for the underpayments together with a complete list of scrubbed underpayments, consolidating claims identified by both Triage and the client’s Patient Financial Services staff. To further boost the argument, Triage came prepared to discuss industry payment protocols for this issue. In addition, Triage presented the legal department with a proposed draft of a legal demand letter setting forth the facts of the claim ready to be pasted onto the client’s own legal letterhead.
Based upon Triage’s presentation, Tenet agrees to litigate. Triage briefs Tenet’s outside counsel and provides expert testimony in the trial case.
RESULTS
The judge rules in favor of Tenet and orders the health plan to make full restitution, including reimbursing attorney’s fees.
