Revenue Recovery

The Challenge

Over the last decade, healthcare costs have risen, on average, more than inflation.  As costs continue to rise, hospitals must continuously work to maximize their recovery of every dollar of revenue due to them from insurance companies.  Opportunities for increasing revenue include improved contracting with managed care companies, staff education and training, the development of a systematic process of reviewing claims to identify underpayments, and an active revenue recovery process.

The Solution

The Horizon Group is dedicated to enhancing the financial and operational performance of our clients by providing personalized services that meet the unique needs of each client and empowering our clients to build their own internal expertise.  The Horizon Group provides a comprehensive approach to maximizing the hospital’s managed care reimbursement by developing an internal managed care recovery unit which operates intimately with the contract department and patient financial services (PFS) department.  This is the key to ensuring that each of these departments is operating at its peak performance.  Our approach is customized for each client and is guaranteed to be successful or we will return our fees.

By developing an internal managed care recovery unit, the hospital can generate significant additional revenue by ensuring that it is being paid according to the terms and rates dictated by its agreements with management care companies.  This auditing team can also provide essential information back to the contracting department and the PFS department that can be used to help avoid underpayments in the future.  This new structure will provide multiple benefits including:

• An increased understanding of the strengths, weaknesses, and financial impact of its managed care payor contracts
• Ability to make intelligent and informed decisions regarding contract renewals, terminations, and renegotiations
• An internal reporting process that provides continuous evaluation of key performance indicators
• Reduced AR days outstanding
• Increased cash flow

The internal unit consists of a lean group of specialized individuals.  The size and complexity of the team will depend on various factors that are identified during the second phase of the process.  As a result of developing the internal unit, both the PFS department and the contracting department are strengthened.

Our Approach

Phase 1:  Feasibility Study
This stage is the first step to determining the feasibility of developing an internal managed care recovery unit.  Several key areas will be analyzed to determine if an internal unit is needed. 

What to expect:

• A small amount of time from the IT department to extract a sample set of data
• Collection of a few key performance reports and managed care contracts
• A detailed report of the pre-audit results
• A decision on whether to proceed with the development of an internal recovery team or not

Phase 2:  Customization & Preparation of MCRU
The second stage of the process is to analyze your specific situation.  This involves collecting various types of information which will be imperative to developing a personalized plan for the unit. 

What to expect:

• On-site visits by key staff from The Horizon Group to interview senior staff within the hospital
• Collection of information from the Contract Department, PFS Department, and IT Department
• Presentation of a customized plan for the development and implementation of the Internal Managed Care Recovery Unit
• Discussion and finalization of the plan with key senior staff from hospital
• Interview and Hire Process for open positions

Phase 3:  Coaching
Once all required positions have been filled, the training process will begin.  This is an essential phase to the success of the program.  So often proper training and education is overlooked, which results in decreased revenue for the hospital.  By providing a comprehensive training program, each individual hire will be given the foundation needed to succeed in his or her job.  We provide this service by using the “Coach Approach” which means that dedicated “coaches” are assigned to the hospital in order to walk each individual through their training.  These coaches will be available throughout the training, implementation, and post-implementation phases and are an essential part of making the unit a success. 

What to expect:

• Specialized Classroom Training (Analyzing Claims, Collecting Underpayments, Rate Sheet Development & Maintenance)
• Extensive one-on-one “Coaching” of new unit
• Allotted time with key staff from the PFS and Contract departments to ensure everyone understands the improved workflow and communication channels

Phase 4:  Implementation
While both the initial development of the program, as well as the training will involve working under “live” conditions, not all processes are actually implemented until this phase of the process.  This stage requires all processes to be put to the test and the Managed Care Recovery Unit should begin to operate with minimal guidance from The Horizon Group. 

What to expect:

• Go-live (all planned workflow changes and improvements are implemented)
• Continued Coaching
• Focus on MCRU team lead (issue identification & resolution, leadership training, team motivation & goal creation, communication training)
• PFS Director Informational Sessions

Phase 5:  Post-Implementation Evaluation
As with any type of project or program development, there must be a means of evaluating the effectiveness of the changes made.  During the established timeframe of the project, The Horizon Group will come back periodically and provide a comprehensive evaluation of the progress of the new unit.  Our professionals are also available for unlimited telephone and email support during the recovery unit’s first year.

What to expect:

• Comprehensive review of all areas of the Managed Care Recovery Unit
• Resolution of any outstanding issues with the newly developed unit
• Periodic Evaluation Report