Why You Shouldn't Cherry-pick Your Biggest Claims for Medicare Compliance

Posted by Kendell Gracey on Nov 6, 2014 2:17:00 PM

We're going to jump up on our soapbox for a moment here, so bear with us.

We've noticed a common trend among our competitors that just really rubs us the wrong way.  Many companies offering to handle Medicare compliance for P&C insurance carriers recommend focusing on the largest claims.  Insurance carriers may even think this strategy is the industry standard.

But it's not.

What we're talking about is cherry picking the largest claims for Medicare compliance review and closure and ignoring the rest.

Now, it's obvious why so many companies go this route: it takes less time, it provides impressive-looking results for the client, and it rakes in high profits for the company handling the Medicare claims.  If you're a smooth-enough talker, it can sound like a win-win for everyone involved.

But it's NOT in the best interests of the insurance carriers.  Here's why:

High-value claims only account for 20% of your total claim volume.

Claims with a settlement value over, say, $100,000 represent a large portion of current and future financial risk.  The possibility of mitigating some of that risk and ensuring that the final product is fully Medicare compliant is understandably attractive. However, the average client produces a fairly small number of these large claims.

In fact, the number of claims handed over for Medicare compliance review and negotiation at this value most likely only account for about 20% of the total number of claims in process involving Medicare beneficiaries. 

That means 80% or more of a carrier’s claims are still at risk for Medicare liens, fines, and even Department of Justice inquiries. These claims are being left untouched.

Taken in aggregate, the financial risk wrapped up in the smaller claims, perhaps costing $5000 or less, likely outweighs the group of cherry-picked large claims that were reviewed, closed, and profited on. 

Your goal should be 100% compliance, not 20%.

medicare_guaranteeAlthough the individual paid costs of each small claim may seem insignificant, the total pay out adds up fast.  Perhaps $2000 is not a lot, but multiplied by hundreds or thousands of claims over the course of a year, this could represent millions of dollars in inflated paid costs, which has a direct impact on your bottom line.

Secondly, while ensuring your highest-value claims are Medicare compliant and paid accurately will save hundreds of thousands of dollars, failing to ensure your lower-value claims are also compliant and paid accurately can cost even more.  Not just the millions in overpayments from quickly processing claims without eliminating unrelated charges from Medicare, but potentially substantial losses from damages and interest paid as a result of non compliance.

How is Flagship Different

At Flagship, our goal is 100% compliance for our clients.  The most effective way to achieve this – and the only way we can guarantee it – is for us to review every single one of your claims, the top 20% AND the other 80%.

Our proprietary LumenX claims review system allows for convenient and fast uploading of electronic claims files for quick review and processing.  We'll review every single claim looking for Medicare involvement and set those claims aside for deeper review.  This ensures you don't accidentally miss a Medicare-related claim.

Then, we'll have our trained and knowledgeable staff review every Medicare-related claim – whether it's seven-figures or three-figures – with the same level of professionalism and attention to detail.  We'll vet the figures to make sure you're not paying Medicare back for any unrelated charges. Then we'll work directly with Medicare to negotiate a final reimbursement amount.

Unlike our competitors who are seeking the fastest, highest profits, then moving on, we're interested in a long-term relationship with our clients.  To accomplish this, we offer the best possible solution in a format that results in a 100% compliance guarantee.

Getting down off the soapbox now.  Contact us for more information or to see how we can help.

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Topics: Compliance