Centaur for Providers
Is it costing you too much to get paid?
- $110 average cost to manage each denied claim through to adjudication
- ~$300B in denied claims annually
- 90% of denials are preventable
of all claims are denied on average
of denied claims are not resubmitted
are written off per year on average per provider
Effective Denial Management
Denial management is a crucial part of a provider’s revenue cycle management program. We work with our customers to manage denied claims, increase billing, and implement lasting improvements.
With our Centaur technology and Denial Management Services, we help minimize and eliminate the cost and disruption caused by denials and audits. Our services are the ideal solution for defending against revenue loss and administrative workload escalation. We provide assessments quickly identifying how we will impact a provider’s financials, no matter how large or small.
We manage denials and control costs as a critical component of Revenue Cycle Management.
Your organization spends a substantial number of resources while managing the “basics” of the claim revenue cycle:
- Lack of payment transparency
- Inaccurate or unfair payment
- Payment reconciliation and claims follow-up
- Administrative hassle for your busy team
- Varying types of denials
Denial Management Services
Most industry service offerings related to Denial Management involve complicated ways of structuring the many moving pieces of Revenue Cycle Management into the solution. At Sharecare, we have designed a way to take the known culprit and place a framework around the entire operational component without all the guesswork. Gone are the days of not having a hard Return on Investment for the solution being evaluated, along with a clear path to success.
Denial Management Services is the critical “gap closure” your practice is looking for. Denials come in two forms. A hard denial and a soft denial. Many will claim that a hard denial is not appealable, but this is incorrect. We look at the hard and soft denials as though they all have the possibility for recovery. We furnish regular reports with rich data needed to know what is recoverable, what is not, and why denials occurred. Through our education and reporting feedback, we will slow, and in some cases stop denials.
- Non-Covered Charges
- Coding/DRG/APC/Modifier Errors
- Overlapping Claims
- Duplicate Claims
- Expired Time Limit
- Demographic and Technical Errors
- Incorrect Plan Code
- Missing Social Security Number
- Audits – RAC, ZPIC, Line Item, etc.
- Excluded Charges
- Overlapping Claims
- Split Bill
- Duplicate Bill
- Contractual Exclusion/Obligation
- Patient Obligation
- Billed Wrong Company
- Transcription Errors
- Medical Necessity
- Charges Applied to Another Practitioner
- Case Management Denial of Services
- Diagnosis Inconsistent with Procedure
- Expenses Incurred After Coverage
- Coordination of Benefits
- Diagnosis Not Covered
- DOB Follows DOS
- Government Review/Audit (Medicare/Medicaid/Advantage)
- Professional Fee
- Technical Component
- Accommodation Code (Incorrect Unit)
- Inpatient vs. Outpatient
- And More
Let Centaur Claim WRX and your Sharecare team make sure you get paid for your hard work.
Features and Benefits
- Highly Trained and Experienced Review/Audit Team
- Detailed Reporting with Centaur Claim WRX
- Continuous Process Improvement/Education
- Maximizes Potential Gains
- Identifies Trends
- Creates or Improves Review/Audit Policy
- Hands Off Approach – Lean on Us!
- Vulnerability Assessment
- Reduces Reimbursement Delays
Audit Management Services
Sharecare Payment Integrity not only identifies billing problems but also provides the technology to make sure you are paid efficiently and accurately. Our Audit Management Service includes:
- DRG Validation
- Retrospective Audits
- Concurrent Reviews
- Zero Balance Audits (Finding Missed Dollars)
- HEDIS, RAC, CERT, ZPIC Auditing Support
- Audit Policy Creation and Management
- Missed/Late Charges
- Quality Reporting (MIPS/MACRA)
- Executive Reporting monthly showing your “at risk” dollars, your monthly reviews,
- Healthcare audits, when managed through our process, can be a highly effective cost containment solution.
- Sharecare Payment Integrity provides powerful Centaur technology and services to enhance revenue, control costs, and defend against denials and audits.
- And More
Managing the Audit Process
Effective audit/review management is critical to cash flow and revenue optimization. Surprisingly, many health care providers have limited policies to protect against auditing threats, which can leave a provider exposed to an endless number of costly audits. Our team helps providers develop and refine audit policies that make cost containment and revenue cycle management “All together, better.”
- Deep dive into the clinical documentation within the electronic health record, coding summary, and the claim for comparison.
- Centaur Claim WRX creates your case adjudication for re-submission to the payor.
Define Corrective Actions
- Admission status, coding, clinical documentation improvement (CDI), readmission and medical necessity reasoning, utilization, and more. Centaur Claim WRX tells you “why” the loss or gain occurred.
Educational Feedback Loop
- Receive detailed reporting and analytics to reinforce root cause findings and their corrective action. Reduce risk and optimize MIPS/MACRA outcomes. Send that clean claim the first time!
Managing the appeal process
Following re-submission of the adjudicated claim, if appeals are necessary, Sharecare’s team of auditors will manage your appeal through to its final adjudication. We will track appeals for your entity to reflect “winning and losing data” to educate and adjust, if possible, for the future claim submission. Our goal is to slow or stop incoming review/audit requests.
Over 70% of appeals when performed are won either partially or in total. We review and store win strategies into our knowledge library to share with your practice our techniques to win. Common winnable appeals include:
- Pre-Certification or Authorization Was Required, but Not Obtained.
- Claim Form Errors: Patient Data or Diagnosis / Procedure Codes.
- Claim Was Filed After Insurer’s Deadline.
- Insufficient Medical Necessity. …
- Use of Out-of-Network Provider
- Peer-to-Peer appeals
- Audit/Claim Review
- “Routine” Supplies and Services
Let Centaurs Claim WRX settle your matters, save you time and hassle, and benefit that bottom line.
Centaur Claim WRX
Centaur Claim WRX is a HIPAA/HITECH compliant Salesforce Cloud based app offering rich reporting ability and visibility into complex workflows. It provides a real-time view into the status of claim denials in process by Sharecare utilizing SaaS model. Advanced drill-down visibility to the specific reviewing/auditing occurring on each claim is a strong benefit for all involved. Review/audit priority can be adjusted by either Sharecare or Customer according to needs.