Expertise

Our mission is to create, analyze, and advance entrepreneurial ideas to support the health care industry. HealthCare Futures serves to deliver business and technology solutions to health care providers that address financial/revenue cycle, operational, and clinical opportunities.

Liability Exchange

The Opportunity:

Health care providers, such as physicians and hospitals treat millions of patients every year who have suffered injuries dues to accident.  Many of these cases are a result of a motor vehicle accident (MVA).  A third party, such as an auto or property insurance carrier may be liable for patient payments in addition to payments providers receive from health insurance carriers.  Most hospitals and physician offices lack the experience and inherent knowledge to establish an internal legal and patient financial service (PFS) infrastructure required to effectively collect from non-health care third party insurers.  Provider PFS staff are trained and experienced in collecting "bread and butter" accounts such as commercial insurance, Medicare, and Medicaid.  Most providers consider MVA accounts to be a low priority.  Many outsource MVA claims for collection to local law firms that are only staffed to file liens.  Those who retain MVA accounts for recovery, typically use a disconnected, fragmented approach, which results in writing off most of the MVA or other accident charges that they are entitled to collect.  It is left to individual account managers to track and chase these MVA accounts, usually with no structured, formalized technology-based collection tool.  Liability Exchange views MVA accounts as a significant opportunity to increase cash in an era of decreasing reimbursement from the core health care payers.

The Solution:

Liability Exchange has created a process for managing and collecting third party claims that is embedded into its proprietary software technology.  Developed by health care insiders, this claims processing technology can significantly increase any provider's cash flow by converting contractual write-offs into cash.  Liability Exchange's dual business process approach protects the legal position of the provider and delivers an expedient approach to negotiating a settlement with an auto carrier.  It is a balanced, stratified approach designed to accelerate payment from liable auto insurance companies.  In many accident cases, the provider usually has the strongest legal position for receiving payment.  For many years, providers have been conditioned to take a passive approach to maximizing their legal position on MVA claims, and have settled for pennies on the dollar.

Liability Exchange has created a proprietary technology PFS collection tool for provider staff to maximize cash collections on MVA claims, minimize write-offs, and recognize the hidden value of treating patients involved in MVAs.  The Liability Exchange system is an intricate series of MVA process recovery decisions that provides for the opportunity to obtain priority position for payments from an adjustor.  Through its unique decision tree, Liability Exchange forces an expedited collection outcome.

Advanced Denial Recovery Solutions

The Opportunity:

Commercial managed care, commercial indemnity plans, and state Medicaid programs are responsible for most hospital denied claims for payment.  Compliance to payer rules and regulations regarding the provision of services is required to ensure payment. If there is non-compliance, the claim will be rejected and not paid. Services will have been provided without compensation and a write-off will be incurred.

A denial rate of 3.0% or less on initially-submitted claims is an industry expectation. A hospital needs a means to identify and quantify its denial rate. The lower a hospital’s denial rate, the more cash it collects. A denial management application, designed specifically for revenue cycle end-users, can significantly contribute to improving a hospital’s bottom line. More cash, less write-offs. Effectively managing denials favorably impacts the hospital’s financial performance and is an important factor in successful revenue cycle operations. Minimizing denials is essential to maintaining financial viability and positive margins.

The Solution:

An application for managing denials provides a hospital with a key tool in maximizing its cash flow.  Effective denial management requires an approach that efficiently identifies, tracks and reports third party payer denials using a discrete denial database.  Advanced Denial Recovery Solutions integrates an algorithmic account workflow in its software system process, which should result in 75% of all initially denied accounts being recovered when appealed, and the goal of a 3% (or better) denial rate being reached.  This is accomplished by addressing specific "breakdowns" commonly seen in existing processes, examples of which include:

• Data collection errors which negatively affect timely billing and reimbursement, and create unnecessary, costly repetition of work
• Lack of verification of patients' insurance eligibility and coverage
• Failure to obtain required payer authorization for procedures
• Failure by case management staff to inform the attending physician that the patient does not meet clinical criteria for admission
• Coding errors by HIM staff, resulting in an incorrect DRG assignment
• Non-compliance by billing department staff to follow third party payer's billing requirements

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All of these breakdowns will affect the flow of an account to payment. Identifying the reason and the source of the breakdown which led to the denial, is essential to reversing the current denial and to preventing future similar denials. Quantitative denial data helps a hospital conduct an objective root-cause analysis of process breakdowns associated with specific denials.

Hospitals using the Advanced Denial Recovery Solutions application benefit from:

• ​Software design tailored specifically for revenue cycle management and staff
• Easy implementation into the hospital's daily workflow
• Minimal requirement for IT support
• Process ownership resides with revenue cycle management staff
• High level automation, with easy access and account flow navigation
• Application tailoring which results in a mirroring of hospital collection protocols
• Relational database, enabling data to be applied as useful management information
• Root cause analysis of denials
• Design optimization for ease of use in identification, tracking and reporting of hospital's denials
• Cumulative denial database profiling capability for continuous monitoring and trending of denials over user-defined time periods
• Expanded analytical capabilities on denied account data elements
• Resource allocation to appealable and recoverable denied claims
• Denial monitoring via a "closed loop" management reporting functionality
• Reduced account re-work, as a result of defined process compliance in initial workflow -- things are done correctly the first time
• Standardized, systemic recovery logic for all denied claims
• More cash, fewer write-offs