PAYMENT INTEGRITY SERVICES
Hospitals/Revenue Cycle Managers
Hospitals and other Revenue Cycle Managers are not in the business of data mining and other data strategies for providing in-house payment integrity solutions. This lack of data strategy has had an incredible impact on Hospitals in the last five years. With the trend related to hospital revenue statistics, now more than ever, you need a strong partner. One who has the knowledge, data analysis tools, claims, and litigation staff to properly identify, analyze, process, and litigate your claims.
4600Boehm will be that partner. We have provided these services to hospitals and revenue cycle managers for over 40 years. We have proprietary data mining tools that help us to maximize case identification without staff burden to you. Our dedicated claims analysts and payment integrity specialists analyze your claims for maximum recovery potential. For those times when litigation is necessary, Additionally, 4600Boehm has a staff of in-house attorneys and litigators when litigated services are required.
HOSPITAL PAYMENT INTEGRITY SOLUTIONS CASE STUDY
Confidential Client: Southern California Hospital
The injured party had worked as a security guard for a car dealership. He arrived at work early and was shot and critically wounded by an assailant before the start of his work shift. Initially, the employer, a security company, had indicated that it would initiate payment of benefits on the claim. Furthermore, they had indicated to the admitting hospital that it would pay for the treatment. However, upon discharge from the hospital, the employer reneged on its promise to pay and denied the claim. They asserted they had no liability because the applicant was not working at the time of the injury.
The hospital referred the matter to our offices. In the course of pursuing recovery, we discovered that the employer, who had been holding itself out as legally self-insured, was actually covered by a workers’ compensation carrier at the time of the injury. The claim had never been reported to the carrier.
4600Boehm’s Payment Integrity Solutions
Without delay, our office set up the claim with the carrier, who denied liability. Multiple attempts were made to reach the injured worker, who had never pursued a claim or case against the employer. It was learned that the applicant struggled with homelessness. In the course of discovery, we learned that the patient, who had multiple internal and orthopedic medical complications from the original attack, had had a lengthy inpatient hospitalization with another government-based medical provider due to the severity of his injuries, resultant disability, and housing challenges,
Furthermore, in order to prevent the expiration of the statute of limitations, we filed the application for adjudication to open a case with the Workers Compensation Appeals Board and filed the liens of our clients in this case.
We obtained authorization to retain a private investigator to track down the injured worker. However, we were able to make telephone contact with the injured worker. We advised him that the employer was insured for the incident and that we had set up a claim with the insurance company. We advised that the claim was currently denied but that we believed that there was a chance that his injury might be deemed compensable, although we could make no promises. He explained that the employer had had him discharged from the original hospital (UCI) to a hotel, where they paid for him to stay briefly.
However, he said that there was another issue. While in the hotel, the employer told him that the claim was not compensable because his shift had not started but that they tendered to him a settlement of $80,000 due to compassion. He had taken the settlement. He said that those funds were long gone due to his medical challenges and that he had consulted with some other attorneys later who had told him he had no chance of recovery due to his $80K settlement with the employer.
We acknowledged the complicating factor but suggested that he consider pursuing the claim nonetheless in order to explore the possibility of recovery on the claim. He consulted with a new attorney whom we had suggested and pursued his claim.
4600Boehm’s diligence in finding the patient, discovering the employer’s true insured status, initiating the workers’ compensation claim with the carrier, and filing the application to open the case with WCAB resulted in: