Underpayments pose a significant challenge for providers in revenue cycle management, as shared in our recent articles on navigating the issue and the causes and implications of underpayments . These elusive revenue shortfalls occur when payers do not reimburse the full eligible amount for services rendered. To tackle this issue effectively, healthcare organizations can follow a structured seven-step framework for quantifying underpayments and maximizing revenue recovery.
Step 1: Analyze Data
Start by collating accounts with a zero balance that have already been paid, specifically those without denials. Performing a zero balance analysis (ZBA) is crucial to identify underpayments that often go unnoticed. It provides the foundation for quantifying the issue accurately.
Step 2: Identify Net Revenue
Next, identify the appropriate eligible reimbursement amount for each account by analyzing various contracts, carve-outs, and fee schedules. This step can be labor-intensive and challenging when done manually, emphasizing the need for robust contract management technology.
Step 3: Calculate Underpayment Opportunity
Determine the underpayment opportunity by applying industry benchmarks. For example, the MGMA benchmark range of 7% to 11% serves as a reference point. Additionally, analyze underpaid amounts by financial class to refine your estimate further.
Step 4: Determine Recovery Opportunity
Apply a recovery rate based on historical data and account for false positives. While benchmarks provide a gross opportunity, not all underpayments can be recovered. Apply a conservative percentage to estimate realistic recoveries.
Step 5: Evaluate Technology Costs
Determine the technology costs required to pursue underpayments effectively. This may involve implementing new technology, optimizing existing systems, or loading new contracts into contract management technology. Technology is essential for streamlining the process and achieving accurate results.
Step 6: Assess Services Costs
Evaluate whether reallocating or adding internal staff is necessary to pursue underpayments. Alternatively, consider partnering with external underpayment service providers to manage the underpaid claim workload cost-effectively.
Step 7: Calculate ROI
Finally, calculate the return on investment (ROI) by subtracting the technology and services costs from the revenue opportunity. This step provides a clear picture of the net opportunity for revenue recovery.
Conducting a comprehensive data analysis empowers healthcare organizations to gain insights into their resources' efficiency, payer behavior, and claim lifecycles and provides a proactive approach to address underpayments and optimize revenue recovery. Performing the analysis on an annual or fiscal basis establishes an annual recurring ROI.
As underpayments persist, implementing technology and services can lead to consistent revenue recovery year after year. However, despite the potential benefits, underpayment teams often face challenges, including capacity constraints and budget limitations. Healthcare organizations that adequately resource underpayment teams and consider outsourced staffing models can take advantage of the opportunity to maximize revenue and increase financial sustainability.
Watch our webinar, “Underpayment Recovery and Its Impact on Your Bottom Line” to learn more about how to leverage this structured framework, and watch for the next article in our series that shares strategies and best practices for managing underpayments.
Matthew Bridge
