Our Services

Claim Underpayments

Do you monitor payer payments on your claim submissions for 100% accuracy of the expected payment established from your contracts? If not, you’re potentially leaving money on the table if you’re not obtaining accurate payments (within a penny) on all your patient account billings.

At PACER, we review your 835 paid claim files from your Commercial Managed Care, Medicare Advantage and Medicaid Managed Care payers and analyze from your billed and paid claims, the allowed amount as compared with the expected reimbursement established by your Contract Management system. If the amounts are not within a penny of each other, then you may be either overpaid (unlikely, giving the high degree of testing and claim processing accuracy by the payers) or underpaid (more likely, but further review is required, since the error may actually exist on your end due to untimely or inaccurate payment rate information loaded into your Contract Management system). Either way, you need to determine why the amounts don’t match.

PACER does the due diligence, determines if your charges are set appropriately based upon highest payer reimbursement, examines the coding and modifiers found in the CDM, determines if any services were not covered, examines if any payer edits were applied in denying service payments, and provides the summary analysis as well as the details with an explanation for all claims where actual payment (allowed amount) is different from the expected reimbursement, and why.

Managed Care Contracting

Having worked in leadership positions for both premier health systems and one of the leading BCBS payers nationwide, I’m a subject matter expert when it comes to negotiating contracts with payers on behalf of hospitals, ASCs and physicians. With the inception of Price Transparency regulations set in place by the federal government over the past four years, now you’re able to see what payment rates are being made to your competing providers from all the Commercial Managed Care Payers and eliminate payer’s pushback who claim that your rates are strong, but cannot disclose how strong due to “proprietary” reasons. Now, seeing is believing.

At PACER, we provide comprehensive payer contracting services, conduct necessary analysis and assessments on the strength of your contracts from a profitability and contribution margin basis, as well as determine how you can leverage your internal strengths (quality, cost, and patient satisfaction/outcomes), to obtain desired payer net revenue and payment percentage rate increases, inclusive of carve-outs and must haves.

Our contracting services work most effectively when we’re behind the scenes, scripting the necessary communications for you to use out-front in your negotiations and providing all the data analysis and NPR impacts from your proposal(s) to reach a satisfactory new payer contract agreement that’s truly competitive with your peers in your market.

Bottom line, we know what to ask for, we know how payers behave and we leverage our longstanding relationships with payers to reach desirable new rates and agreements for our client providers.

Payer Charge Audits

Payers are increasingly relying upon contracted consultants and vendors to conduct charge audit reviews of provider claim submissions and payments. The problem is that these contracted vendors lack competency, are not subject matter experts and rely upon incomplete or inaccurate sources in determining whether provider billable services are appropriate and allowable. The end result is summary findings of charges that are deemed not allowable, outlier overpayments due to charge removals and payment clawbacks.

At PACER, we dispute the conclusions, fight the findings and appeal the recoveries where necessary, because facts matter and we provide support for billing the services, cite industry recognized organizations (CMS, NUBC, AMA, AAPC) as our definitive sources for determining whether a provider’s charge is allowable and appropriate, and negate conjecture or perceived charging problem conclusions made by the auditors to justify their payment clawbacks. Our conclusions are backed by third-party arbitrators when the findings go through the appeal process.

We have a nearly 100% success rate in overturning payer disallowed charges on paid claims resulting in recoupment of payer payment takebacks that in aggregate are in the tens of millions.

Claim Denials

In today’s healthcare fiscal landscape, no hospital, ASC or physician practice is immune to payer claim denials. It’s a true statement that the financial health of a healthcare organization can be measured in denials. Whether it’s No Authorization, Not Medically Necessary (whole or partial), Not our Member, Coverage Termination, Bundling or Mutually Exclusive, Noncovered Charges, Prior Payer Adjudication, Untimely Filing, DRG Downgrades, ED Visit Downgrades, or Missing Clinical/Claim Information, unresolved claim denials can represent an average loss of up to 5% of net patient revenue.

So, what can you do? Let PACER create a Denials Prioritization Strategy Template with Processes specific to your organization to help you to:

Improve efficiencies in denial processes (prior authorizations should consume less time through payer automation within their portals and establish best practice workflows; what needs to be communicated, through what mechanism (email, fax) and within what timeline?
Utilize electronic eligibility and benefits verification systems to avoid coverage denials.
Ensure familiarization with specific authorization requirements and policies by payer to ensure compliance with coverage criteria.
Identify the root causes of eligibility denials and implement corrective actions to prevent re-occurrences.
Timely respond to denials with necessary follow-up; focus on effective communications with payers and internal departments (Registration, HIM/Coding, Case Management).
Track your denials with KPI metrics (group denials by payer, reason, CARC code, denial category, services/areas, dollar amount and appeal success rate with dollar amount).
Establish Denial Account Management Reports, Resolution Summary, Transaction Summary, A/R Account Aging, Account Overview, Account Analysis).
Strive to achieve a first pass clean claim rate of 95% or greater for all payers.
Keep Leadership informed of Denials Summary, Trending Analysis and Process Improvements.

Our Denial Management Team conducts comprehensive reviews and analysis of your claim denials and processes in order to understand what’s being done to resolve and mitigate them and what improvements can take place, based upon best practice initiatives. Issues are identified, predictive denials and risk pattern identification are deployed and recommendations made for achieving first pass clean claim submissions. Metrics, monitoring, and data scorecards are utilized extensively in telling the complete story in order to present where you’re currently at and where you need to be at. We help you get there.

Cost Management and Decision Support

I’ve implemented cost accounting and decision support systems at some of the largest health systems on the East Coast with a Team of dedicated professionals driven by the creation of something transformational (having the ability to recognize profitability and contribution margins across service lines, payers, DRGs and physicians), as well as recognition being at the table on key strategic decisions on service expansions, capital project expansions, mergers and acquisitions, payer contract renegotiations, and cost containment/workforce reduction initiatives. It’s exciting to know you helped create a reliable cost structure that was invaluable in shaping the direction of the organization, driving fiscal responsibility and being attentive to beneficial new opportunities.

At PACER, we assess a provider’s cost structure from the ground-up, evaluating each and every billable service found within the provider’s CDM, establishing a direct cost component (based upon labor-related time costs, room location costs, supply and drug costs) as well as an allocated indirect overhead cost from non-revenue generating departments. All costs are reconciled with the hospital’s total operating expenses found in the MTD/YTD financials, to ensure accurate and fully accountable expense distribution to the revenue generating services.