HOME » Additional Documentation Sought for Underpaid Claim Case Study

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The hospital admitted a patient for seven inpatient days. The patient had coverage with Medi-Share, a religious non-profit organization that is not an actual insurance company. Upon receipt of the claim, they conducted a bill review to verify that the charges were billed correctly. After doing so, they issued payment on the claim, but disallowed $171,810.81 in charges as not documented.

Convergent requested medical records to examine the disallowed charges accordingly. At the client’s request, Convergent analyzed the nature of the specific reductions to allow the hospital to tailor its medical record production in a manner that targeted the specific areas of concern. For this purpose, Convergent contacted Medi-Share and demanded a copy of the actual audit documentation. After receipt and review of this documentation, Convergent worked with the hospital to limit the medical record request to the greatest extent possible while still facilitating a productive appeal.

After the provision of the targeted medical records produced by the client, Medi-Share in turn narrowed its focus to several smaller categories of review. As a result, Convergent worked with the hospital to obtain and forward additional medical documentation specifically addressing these concerns, to document the provision and quantity of services in question.

After continuing to work with Medi-Share, and specifically addressing each additional documentation issue raised by them with appropriate documentation from the client validating the services, Medi-Share ultimately agreed to allow an additional $171,346.14, reducing the charges disallowed on the claim to only a few hundred dollars.

Convergent worked with Medi-Share to ensure that the check for the additional allowed amount was issued in a timely manner, and subsequently verified that the hospital had received the additional payment to bring the case to a final resolution.