Services
Insurance Follow Up
& Managed Care Disputes
Medical Accounts Systems has a division that exclusively pursues payment from Managed Care Organizations, Medicare, and Medicaid. In addition to bill submission/resubmission, MAS appeals underpayments, denials based upon lack of prior authorization, lack of medical necessity, pre-existing medical conditions, out-of-network underpayments based on usual and customary rate disputes and partially approved hospitalizations (carve-outs), among other things.
Our Managed Care division is comprised of aggressive and experienced professionals and support personnel dedicated to securing recovery from commercial and government payors. These qualified individuals have special knowledge and understanding of the managed healthcare industry, possess the ability and skill to interpret managed care contracts and understand billing and reimbursement policies, and can navigate successfully through the complex grievance and appeal process.
MAS relies on healthcare practitioners, including physicians, nurse practitioners and licensed psychiatrists to review medical records, assess admission criteria and substantiate medical necessity.
MAS frequently encounters and provides appropriate solutions for the following:
- denials for untimely filing
- denials for lack of authorization
- denials based on lack of medical necessity
- contractual carve-outs
- underpayments under non-participating provider statutes
- Emergency Medical Treatment and Active Labor Act (EMTALA) disputes
- Employee Retirement Income Security Act (ERISA) benefits denials
- out-of-network underpayments based on usual and customary rate disputes
The presence of healthcare attorneys at Medical Accounts Systems gives the agency an unparalleled advantage when addressing these revenue draining issues. Additionally, MAS possesses the technology and infrastructure to identify and resolve denials, underpayments and carve-outs on an aggregate basis.
Case Study
Issue:
Medicare denied the claim stating the diagnosis inputted on the claim indicated a Worker’s Comp (“WC”) injury, and so the WC holds primary payer responsibility.
Analysis:
Following MAS’s review of the medical records, the patient fell at home and so treatment was not related to any WC claim. MAS contacted the Medicare Benefits Coordination and Recovery Center (“BCRC”) and discovered that the patient had several WC claims open.
MAS team contacted the WC company and secured Letters of Exhaustion of Benefits (“LOEs”) for each WC claim in the system. The LOEs were then submitted to Medicare. MAS diligently followed up with Medicare to ensure that the submitted LOEs were uploaded and populated into the Medicare system to accurately reflected that all WC claims were closed.
Solution:
Medicare system was properly updated and Medicare remitted $29,236.42 to the Provider.