Comprehensive HMO Case Management Includes:
Maximizing Reimbursement for High-Cost Care
For patients receiving IV antibiotics, wound care, extensive therapy or expensive medication, we obtain the highest eligible rate of reimbursement—either for the entire stay or specific dates of service. Our team reviews applicable managed care contracts and authorization requirements to help ensure the approved level of care and reimbursement accurately reflect each patient's clinical needs.
Medication Carve-Out Review
Expensive medication alerts are analyzed to identify potential carve-outs, ensuring accurate billing and minimizing financial loss. Our team reviews applicable managed care contracts to determine whether high-cost medications qualify for reimbursement outside the standard contracted rate.
Continuous Monitoring Through Discharge
Our case managers closely monitor each stay, maintain communication with facility teams, and advocate for authorizations that cover the full clinical need through discharge. Through timely concurrent reviews and consistent clinical documentation, we help minimize gaps in authorization and ensure that approved levels of care remain aligned with the patient's needs throughout their stay.
Single Case Agreements
When a patient's care needs fall outside existing contracted arrangements, we assist facilities in pursuing single case agreements with payers. Our team evaluates the patient's clinical requirements, coordinates with insurance representatives, and advocates for appropriate reimbursement terms that reflect the services being provided.
Clawbacks, Denials, & ADR Appeals
We support facilities in navigating denied claims, payer clawbacks, and additional documentation requests (ADRs). Our team reviews payer determinations, gathers supporting clinical and authorization records, and assists with preparing and submitting appeal documentation within applicable deadlines. We also coordinate with your billing and accounts receivable departments to help resolve reimbursement discrepancies, minimize avoidable denials, and support timely claims processing.
Accounts Receivable Coordination
If you need help processing claims efficiently and accurately, we can help. Through monthly coordination, our team reviews outstanding claims, verifies authorization details, and identifies potential billing discrepancies that could delay reimbursement or result in avoidable denials. By maintaining clear communication between clinical, authorization, and billing teams, we help resolve payer-related issues, support timely claims processing, and protect your facility's revenue.
